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The UMQM Nurse shall also participate in Utilization Management related activities with the Appeals and Grievance Department as well as the Compliance Department to assure that the quality compliance is being met for NCQA, state and federal regulatory requirements.
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Knowledge of InterQual and MCG as well as CMS Last Covered Day or LCD / Non - Covered Day or NCD documentation License, Registration, or Certification Requirements: Current NYS or CT Registered Nurse (RN.
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As a member of SFHP’s the Grievance Review Committee, the QRN supports the Grievance and Appeals team in ensuring that clinical concerns are addressed as part of grievance investigations. Document clinical reviews and provides clinical support and guidance to the Grievance and Appeals Team.
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The Clinical Appeals Nurse will review each case identified/referred for appeal based on Milliman Care Guidelines (MCG), InterQual, and/or other relevant guidelines, determined the viability of the appeal, and manage the appeal process.
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Review incoming grievance and appeals for clinical quality concerns and expedited status. The QRN works closely with the Grievance and Appeals team and the SFHP Medical Director to ensure that clinical quality concerns are addressed in all grievances and appeals.
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The utilization review nurse works with the multidisciplinary team to assess and improve the denial management, documentation, and appeals process of such findings. The position is integral to the organization, as successful appeals by the nurse result in preventing denied claims and preserving revenue.
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Valid California Registered Nurse license or foreign medical graduate. Involved in the clinical denial/appeal process for DRG challenges and clinical validations via Clinical Validation Audits/Denial Prevention, reviewing technical payor denials and determines if an appeal is justified and author appeals.
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An Appeals Nurse Coordinator II will have experience with utilization management, DRG clinical validation, understand the state and federal regulations, have knowledge/experience with the denials and appeals process and have experience with physician documentation and electronic health records.
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Acentra is currently looking for a Utilization Management Appeals Nurse – LPN/RN to join our growing team. Our Utilization Management Appeals Nurse – LPN/RN will help orchestrate the seamless resolution of appeals in line with health regulations.
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Provides detailed understanding or aptitude for resolving denials based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons and constructing warranted appeals for defined populations.
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Report member complaints to Appeals and Grievance team for investigation and follow-up, per protocol. Registered Nurse - Care Coordinator is part of an innovative multi-disciplinary care coordination team addressing OHP and CareOregon Advantage members' needs.
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We offer a training center on campus for continuing education, Shared Governance Program, Clinical Ladder for professional development, The Daisy Award, and if you are a new grad, a Nurse Residency Program to help you transition from student to professional nurse.
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The RN Clinical Appeals Nurse will actively manage, maintain and communicate denial/appeal activity to appropriate stakeholders, and report suspected or emerging trends related to payer denials.
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Communicates to Utilization Management Nurse data supporting denial appeals, or notification of potential denials. Reviews and analyzes third-party payer denials for in house patients, and communicates to attending physician , Case Management, Manager, Utilization Management Medical Director, and Utilization Management Nurse as per department protocols.
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Medical Center Case Manager / Discharge Planner / Utilization Review, Registered Nurse (RN) is responsible for compliance with CMS Conditions of Participation including implementation and annual review of the Utilization Management Plan and coordination of the Utilization Management Committee.
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