What are the responsibilities and job description for the Utilization Management Spec RN position at Fairview Health Services?
Overview
Fairview Health Services is hiring a casual Utilization Management Spec RN to join our Revenue Cycle Management team. This is a remote position.
This position, under Revenue Cycle Management, is responsible for the completion of admission and continued stay clinical review, including obtaining insurance certification / authorization necessary to secure reimbursement. This position assesses the patient’s plan of care and progress of the patient throughout an acute care and / or outpatient episode (observation) across the M Health Fairview system.
Responsibilities Job Description
Job Expectations :
- Perform and document timely and accurate utilization management review to ensure compliance with all policies, procedures, regulatory and accreditation requirements.
- Adhere to applicable professional standards using nationally recognized evidence-based clinical criteria and M Health Fairview guidelines to determine the appropriateness of level of care, length of stay and discharge planning.
- Facilitate secondary physician review with the physician advisor and / or attending physician on required cases to ensure accurate level of care assignment and reimbursement.
- Manage resolution of concurrent payer denials through submission and coordination of appeals related to medical necessity (level of care) and tracks all work related to denials / appeals.
- Educate internal members of the health care team on utilization management workflow and managed care concepts.
- Work on a variety of special projects and assume other duties as assigned by the Utilization Review Manager or Supervisor.
- Understand and focus on key performance indicators.
- Contribute to the process or enablement of collecting expected reimbursement.
- Understand and adhere to Revenue Cycle’s Escalation Policy.
Organization Expectations, as applicable :
Qualifications
Required
Preferred
