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Utilization Management Nurse Jobs

Company

MFS Talent
Address Palo Alto, CA, United States
Employment type CONTRACTOR
Salary
Category Hospitals and Health Care
Expires 2023-08-27
Posted at 9 months ago
Job Description
This is a remote position.


JOB DETAILS


  • Hours/Days: 8:30am-5pm; Saturday - Wednesday
  • Shifts Available: Days- 8 hours. 40 hours/week



  • Physician Advisor Collaboration:
  • Documentation and Reporting:
  • Seek guidance from the Physician Advisor regarding medical necessity criteria, coding, and reimbursement policies to ensure accurate and effective appeals.
  • Review cases that have been denied by insurance providers or other entities and determine appropriate action for appeal.
  • Generate reports and provide data analysis on utilization metrics, outcomes, and trends to support performance improvement initiatives and compliance.
  • Collaborate with internal and external stakeholders to ensure compliance with regulatory standards and achieve organizational goals.
  • Evaluate and analyze patient data, treatment plans, and progress notes to ensure compliance with established standards and guidelines.
  • Collaborate with healthcare teams, including physicians, to gather relevant clinical documentation, supporting medical necessity, and appropriateness of care.
  • Collaborate with healthcare teams, including physicians, nurses, social workers, and other professionals, to ensure continuity and appropriateness of care.
  • Utilize evidence-based guidelines, payer policies, and regulations to build strong appeals that address the reasons for denial and highlight the medical necessity of the requested services.
  • Identify opportunities for process improvement and participate in quality assurance activities related to utilization management.
  • Perform timely comprehensive utilization reviews on patient medical records to determine the appropriate level of care, medical necessity, and adherence to regulatory guidelines.
  • Appeals and Denials Management:
  • Participate in Long Length of Stay (LLOS) meetings to support care transitions and ensure appropriate utilization of resources.
  • Educate healthcare professionals and staff on utilization management principles, documentation requirements, and regulatory updates.
  • Track and trend denials for process improvement.
  • Facilitate communication and coordination among healthcare providers, patients, and payers to optimize patient outcomes and minimize unnecessary healthcare services.
  • Consult with the Physician Advisor to discuss complex cases, medical necessity, and strategies for successful appeals.
  • Care Coordination:
  • Collaborate with the Physician Advisor to obtain additional clinical information or documentation to strengthen the appeal.
  • Compliance and Education:
  • Identify opportunities for improved resource utilization, cost containment, and quality improvement, utilizing metrics such as the Geometric Mean Length of Stay (GMLOS) to benchmark and guide efficiency efforts.
  • Maintain guidelines, federal and state regulations, payer requirements, and best practices related to utilization management.
  • Maintain accurate and thorough documentation of utilization management activities, including reviews, decisions, and interventions.


Requirements


MINMUM QUALIFICATIONS


Education Qualifications


  • Bachelors required and Master of Nursing (MSN) preferred from an accredited college or university.
  • Any combination of education and experience that would likely provide the required knowledge, skills, and abilities as well as possession of any required licenses or certifications is qualifying.


Licenses and Certifications


  • Case Management or Utilization Management certification or willingness to obtain within 2 years of hire.
  • RN - Registered Nurse


Experience


  • Three (3) years of progressively responsible and directly related work experience, preferred.


Benefits


  • 401k
  • Medical/Dental/Vision