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Utilization Review Care Manager RN - 16 Hours
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Part-time
- Essential Functions: ·Application of accepted utilization standards and or nationally accepted medical necessity criteria to all admitted patients in the medical surgical and maternal child health areas of the hospital to confirm correct level of care.
- Act as a resource to nurse CMs and provider physicians for questions regarding utilization management ·Establish positive working relationships with payor CMs·Participate in medical/utilization management activities for those patients whose health plan has delegated medical management to the Newton Wellesley Physician Hospital Organization.
- Ensures level of care changes are completed with accurate event management entry inclusive of communication with patient access to process·Protects the patient health record by transmitting only required information to correct destination·Builds an understanding of the denials process and how it is managed with ability to manage the process if needed·Reviews and manages Medicare one day stays in collaboration with Insurance Support UR nurse and Physician Advisors.
- Other Duties ·Collaborate with physicians, case managers, revenue cycle personnel, contracting and payers to identifyways to prevent clinical denials.
- Participate in Revenue Cycle, Denials, Billing Compliance and Utilization Review Committees/meetings.
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