Utilization Management Review Denials Nurse, RN and Case Manager, RN

Imperial is currently seeking a Registered Nurse with 2 to 3 years of clinical nursing background and 2 to 3 years of Utilization Review experience. The ideal nurse for this role would also be proficient in conducting peer-to-peer meetings, mitigation of denials, have a strong understanding of the preauthorization process, the revenue cycle, reducing financial risk, be able to liaise with providers / staff, and work with payers while having regulatory awareness.

About the Role

The UM Denials Specialist, RN will be responsible for managing the denials process and ensuring compliance with medical necessity criteria.

Responsibilities

• Completes the denials process for requested services and IP hospital stays that fail to meet medical necessity consistent with MCG or CMS criteria.
• Requests and reviews medical records and notes as appropriate; evaluates for medical necessity and appropriate levels of care; collaborates with Medical Directors and other team members to determine response; assures timeliness and appropriateness of responses per state, federal and Imperial Healthcare guidelines.
• Refer cases not meeting criteria for medical necessity to Medical Director during inpatient rounds.
• Identify and refer situations needing immediate intervention to Administrative Director of Managed Care, RN Manager, Medical Director, Quality Assurance and Risk Management, as appropriate
• Develops medical summaries of denied cases for review by the Medical Directors.
• Identifies and implements strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials.
• Identifies system delays in service to improve the provision of efficient and timely patient care.
• Identifies process issues related to the UM concurrent Case Management system, including appropriate resource utilization and identification of avoidable days.
• Assure quality care by adhering to standards set by the physicians.
• Provide care education to patients in person or over the phone.
• Adhere to compliance guidelines throughout processes (OSHA, FDA, HIPAA).

Qualifications

Required Skills