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The Utilization Review Nurse provides clinical review for different healthcare services requiring authorization- including acute inpatient, skilled nursing facility, acute rehab, home nursing as well as others.
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Under the direction of the Director, Care Coordination, the Utilization Review RN performs activities which support the Utilization Management functions. The Utilization Review RN is responsible for the delivery of the Utilization Management process not limited to and including: making clinical recommendations regarding medical necessity for admission and continues stay, screens patients for client specific guidelines regarding insurance, Medicare and/or Medicaid guidelines, send payor specific Notice of Admission and continued stay reviews.
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The Utilization Review Nurse coordinates the communication of care and obtains authorization numbers/certification of approved days for each assigned patients length of stay. The care manager utilization review will monitor the changes in the condition of the patient, monitoring to see if the treatment is working and update the payer on changes in the patients.
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The Utilization Review Specialist manages daily operations, which include supervising the staff performing benefit enrollments and utilization management activities. The Utilization Review Specialist review functions as the internal resource on issues related to the appropriate utilization of resources & services, coordination of care across agency and utilization review and management.
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The Utilization Review Specialist will work as a part of the multi-disciplinary team (MDT) and is responsible for maintaining standards of care and competency, ethical treatment of patients, understanding of addiction and the medications used for detoxification purposes, managing symptoms of withdrawal with comprehensive triage, consistent documentation on care, review and implementation of treatment orders.
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The Utilization Management Coordinator is responsible for all utilization management activities for assigned cases from admission through discharge, including peer reviews and appeals, in accordance with the Utilization Review Plan, for patient population ages 5 years through 21 years, with significant behavioral health needs and Autism Spectrum Disorders or other developmental disorders.
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Provide denial information for UR Committee, Denial and Revenue Cycle Collaborate with Patient Access, Case Management, Managed Care and Business Office to improve concurrent review process to avoid denial or process delays in billing accounts Accountable to identify and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements.
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The Utilization Review LVN uses clinical judgement in providing utilization management services. - Preferred 5-7 years of experience in combination of utilization management prior authorization or acute/sub-acute care experience.
$27.77 - $40.27 an hourFull-timeExpandApply NowActive JobUpdated Today - UpvoteDownvoteShare Job
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UTILIZATION REVIEW / CASE MANAGEMENT RN - Part Time, Weekends. Position Summary: Conducts concurrent and retrospective chart review for clinical, financial and resource utilization information.
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The LVN Discharge Planner performs utilization review by using criteria that demonstrates medical necessity to achieve reimbursement for services and ensuring appropriate utilization of hospital resources.
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Conducts concurrent and retrospective chart review for clinical, financial and resource utilization information. Candidates must have Utilization Review and Discharge Planning experience.
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The role of the Utilization Review Case Manager (UR Case Manager) entails overseeing compliance with the hospital's utilization review plan to ensure the efficient utilization of hospital services.
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Managed care/utilization review experience preferred. Utilizes clinical skills to coordinate, document and communicate all aspects of the utilization/benefit management program.
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Mentor and monitor work delegated to Utilization Review LVN/LPN and/or Authorization Coordinator as needed. Utilization Management services supporting medical necessity and denial prevention.
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Performs utilization management tasks for contracted and non-contracted facilities according to benefits to which the member is entitled, including, but not limited to, utilization review, discharge planning, concurrent review, inpatient and outpatient referrals, after-care, and case management.
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review utilization management jobs Title: sales representative
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