• Reviews admission data to establish the appropriate level of care using Interqual criteria.
• Integrates clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the hospitalized patient.
• Conducts concurrent reviews to determine the continued need for acute care setting, appropriateness and timeliness of treatments/procedures and to optimize the potential for reimbursement.
• Collaborates with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process.
• Collaborates with UR Manager and/or physician advisor regarding cases that do not meet established guidelines for admission or continued stay.
• Acts as a liaison between physicians and payers, coordinating peer-to-peer phone calls.
• Collects and compiles data as required.

It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.

Education/Experience Required:

• Current MA RN licensure
• Bachelor’s Degree in Nursing or advanced degree in healthcare preferred.
• Three years recent, broad clinical experience in the hospital setting
• Experience with utilization management within the last 3 years required
• An understanding of the severity of an array illnesses, intensity of service, and care coordination needs
• Ability to identify appropriateness of patients admission and level of care needs (inpatient & observation) utilizing Interqual criteria
• Knowledged of Interqual required; Allscripts preferred
• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor with patients, physicians, colleagues and insurance companies
• Knowledge of government and insurance company reimbursement policies in regards to admission criteria, treatment and length of stay
• Ability to work independently

Registration/Certification:

• Current MA RN licensure