Utilization Review Registered Nurse (RN)

The Clinical Denials & Appeals RN is responsible for the systemwide retroactive medical necessity review of medical services provided. The Utilization Review Registered Nurse is integral in the revenue cycle on a system level and exists to partner Case Management and the System Business Office to overturn medical necessity clinical denials through the appeal process.

The Utilization Review RN will review and respond to all payer (Medicare, and Medicaid, and commercial) medical necessity clinical denials. The Clinical Denials & Appeals Registered Nurse will identify trends and responds to promote a reduction in the medical necessity denials. The Utilization Review RN is key in revenue recovery and maximization of reimbursement.

Benefits:

• We offer full benefits, clear career paths, tuition reimbursement, and more!

Requirements for the Utilization Review RN:

• Bachelor’s Degree in nursing
• Current NYS or CT Registered Nurse (RN)
• 3 years’ experience in: acute care Nursing; experience as a Utilization Review Nurse in a payer or acute care setting; and experience in revenue cycle management, preferably in a hospital provider environment
• Knowledge of InterQual and MCG as well as CMS Last Covered Day (LCD)/Non-Covered Day (NCD) documentation
• Ability to work in a team environment and form positive, collaborative relationships with hospital staff, providers, patients, and families
• Must be able to manage multiple competing priorities and maintain calm demeanor in stressful environment

Preferred Requirements

• Master’s Degree in Nursing
• At least 3 years of experience in revenue cycle management, preferably in a hospital provider environment
• Experience in billing cycle language and managed care contract language and Experience with Medicare/Commercial appeals/denials

Clinical Denials & Appeals Registered Nurse Responsibilities:

• Reviews all medical and surgical medical necessity denials retrospectively
• Determines the medical necessity for the appeals by reviewing medical records and utilizing clinical and regulatory guidelines
• Discusses with Medical Director(s) or Physician Advisor (s) as needed to establish the appropriate level of care and/or plan for appeal
• Ensures the submission of appeals to the payers within allotted timeframes to prevent fiscal penalties
• Documents and logs appeal information on relevant tracking systems to provide accurate denial data
• Conducts timely review of appealed cases to maximize the reimbursement
• Maintains compliance with HIPAA regulations and accrediting requirements
• Serves as a subject matter expert for appeal and a resource for the team members
• Coordinates activities and strategies with the Case Management Department, Patient Access, Health Information Management, System Business Office, Managed Care, and Physician Advisors
• Maintains and practices a professional image

Nuvance Health maintains a policy of equal employment opportunity and will not discriminate against any employee or applicant because of race, color, age, sex, including pregnancy or caregiver status, gender identity and expression, sexual orientation, physical or mental disability, religion, ancestry or national origin, citizenship status, marital status, genetic information, veteran status or political affiliation or any other basis protected by law.

Schedule a time to speak to a recruiter: https://calendly.com/krys-perez

IND2

Job Type: Full-time

Pay: $39.21 - $72.83 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• Day shift

Application Question(s):

• Please provide us with your email address and phone number.
• Do you have knowledge of InterQual and MCG as well as CMS Last Covered Day (LCD)/Non-Covered Day (NCD) documentation?
• How many years of experience in acute care nursing, Utilization Review in a payer or acute care setting with experience in revenue cycle management do you have?

License/Certification:

• RN License in the state of NY or CT (Required)

Work Location: In person