Utilization Review Rn (Austin, Texas)

Details

• Facility: Automated Benefit Services (ABS)
• Department: Ascension Care Claims Quality
• Schedule: Full-Time, 8-hour day shift, Monday - Friday, Fully Remote

Benefits

Responsibilities

• May prepare statistical analysis and utilization review reports as necessary.
• Proficient with ICD-9, ICD-10, CPT and Coding.
• Assess and coordinate discharge planning needs with healthcare team members.
• Review admissions and service requests within assigned unit for prospective, concurrent and retrospective medical necessity and/or compliance with reimbursement policy criteria.
• Knowledge of Government Insurance Prgram plans.
• Oversee and coordinate compliance to federally mandated and third party payer utilization management rules and regulations.
• Proficient with Insurance Fraud Waste Abuse (FWA) clinical, appeal and technical reviews.
• Assist departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals.
• Provide case management and/or consultation for complex cases.

Requirements

• Registered Nurse obtained prior to hire date or job transfer date required. Licensure required relevant to state in which work is performed.

• Diploma from an accredited school/college of nursing OR Required professional licensure at time of hire.

Additional Preferences

• 3 years of Government Insurance Program plans utilization experience, preferred.
• 3 yeas of nursing experience, preferred.
• Nursing Licensure Compact (NLC) strongly preferred.
• 3 years of Insurance Fraud Waste Abuse (FWA) Clinical, Appeal and Technical review experience, preferred.
• 3 years of ICD-9, ICD-10, CPT and Coding experience, preferred.

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Why Join Our Team

Equal Employment Opportunity Employer