RN, Utilization Review, Authorization Management

Responsibilities\n\nThe Utilization Review RN supports the utilization review program by developing and maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and / or government payers. This individual maintains current and accurate knowledge regarding commercial and government payers and CMS regulations, guidelines, and evidenced based criteria related to utilization review. The Utilization Review RN effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment. They collaborate with multiple leaders at various levels throughout the organization, including clinical providers, managers, directors, for the purpose of supporting and improving the UR program. The Utilization Review RN interacts with outside agencies, third party payers, and managed care companies in accordance with contractual agreements and payer requirements are met with the goal of preventing technical and clinical denials. The Utilization Review RN works towards the resolution of denials by utilizing nationally recognized criteria for appeal submission.\n\nQualifications\n\nRequired : \n

• Three years of acute care nursing\n
• Associate Degree\n
• Registered Nurse (KY)\n\nDesired\n
• One year of utilization review of case management\n
• Bachelor Degree\n
• Accredited Case Manager OR Case Management Administrator Certification OR Certified Case Manager