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Preferred experience with Utilization Review, Health Insurance Denials and Appeals, Payer Audits, or Case Management. The Clinical/Utilization Review Nurse advocates for reimbursement for services provided by the hospital through their review and analysis of complex medical issues.
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Work closely with Utilization Review and Admissions staff to ensure proper authorization of patient insurance coverage. Monitor and report on key metrics such as cash collections, days outstanding, unbilled, denials, daily census, etc.
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Under general supervision, provides utilization review and denials management for an assigned patient case load. Minimum of 2 years experience in case management or utilization management required.
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Partners with finance, billing and coding, patient financial counseling, prior authorization, utilization review, and revenue integrity teams to drive improvements in the organization's revenue cycle and reimbursement processes.
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Provide health care services regarding admissions, case management, discharge planning and utilization review. Registered Nurse RN - Utilization Review. May prepare statistical analysis and utilization review reports as necessary.
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The Utilization Review Registered Nurse (RN) provides a clinical review of cases using medical necessity criteria to resolve the medical appropriateness of inpatient and outpatient services.
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Knowledge and use of discharge planning, case management referral criteria, utilization review and levels of care. Alerts and partners with appropriate Utilization Review, Physician leadership and/or Provider Team personnel concerning patients who do not meet medical appropriateness criteria.
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The Claim and Denial Coding Analyst role is a Certified Medical Coder who ensures clean claim submission and timely review and resolution of coding related claim denials for professional services, FQHC, MSO, and ASCs across the network.
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Obtain and assist medical provider in reviewing the Controlled Substance Utilization Review and Evaluation System (CURES) report. Provide patient support in the clinic including: schedule appointments, enter authorization dates, appointment confirmation calls, medical records requests and follow up on appeals and/or denials.
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Managing Medicare Medical Review and Denials process in conjunction with Director of Rehabilitation, the facility, and therapy staff. Preparing for and providing meaningful contributions to the rehab team conferences, patient care conferences, utilization review meetings, family conferences, and caregiver training sessions.
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Verifies patient’s needs for acute level of care, collaborating with utilization management nurse to prevent potential denials. The care manager shall support and follow compliance rules and regulations and Conditions of Participation for DC Planning and Utilization Review, and address opportunities or potential concerns with leadership.
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This includes but is not limited to:Identifying and correcting safety hazards or notifying the facility or the Director of Rehabilitation so that safety hazards will be immediately remedied. Knowledge of use of prosthetic and orthotic devices ambulatory aides, assistive and resistive devices, and training.
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Supports UM process through accurate and timely communication of review information recorded in MIDAS or Allscripts Care Manager and associated systems to insurance companies including uploading reviews into payer website as required and phone reviews.
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The CPA is expected to be a subject matter expert in Utilization Management including status determinations and denials support. Conducts clinical reviews on cases escalated by the case management, utilization management, and denials teams to meet regulatory requirements and efficient utilization of health care services.
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Serves as an educational resource to all AHN staff regarding utilization review practice and governmental/commercial payer guidelines. Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc.
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