Utilization Reviewer (RN)- Full Time, Days, 8 Am - 4 Pm, Morristown

Job description

• Provides timely and thorough clinical information to insurance companies and other intermediaries to secure payer authorizations and avoid denials or reduction in level of care.
• Performs daily surveillance of observation cases and works with PA discussing any barriers to progression of care or discharge.
• Intervenes proactively to avoid denials or delays in authorization.
• Actively communicates information to other CM team members and interdisciplinary teams regarding progress or payer issues related to continued hospitalization and post-acute service associated with the patients discharge plan.
• Refers cases and issues to Physician Advisors or Designees in compliance with department procedures with timely follow up as indicated
• Assists in identification and collection of avoidable days
• Coordinates with the CM RN and/or CMA to identify and complete the process for CMS required patient notices.
• Completes and documents utilization reviews, physician advisor referrals and other communications related to assigned cases in accordance with department policy and procedure.
• Complies with the Condition of Code 44 process, CMS required patient notices and other regulatory requirements within the utilization management process.
• Maintains proficiency in the application of organization selected clinical review criteria sets evidenced through IRR testing

Graduate of an accredited school of nursing - required
BSN - preferred
Current RN license - required
Case Management - Preferred