Outcomes Manager, Utilization Review – RN, Full Time
Lourdes Health System
full-time
Posted on:
Location Type: Remote
Location: Arizona • Connecticut • United States
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Salary
💰 $77,405 - $123,574 per year
About the role
- Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes
- Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process
- Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity
- Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues
- Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers
- Appropriate and complete documentation of clinical review and denial management in the case management documentation system and in the billing system
- Manages the concurrent denial process by referring to appropriate resource for concurrent and retrospective appeal activity process
- Prepares and facilitates audits using appropriate screening tools and documentation
- Accountable to job specific goals, objectives and dashboards which contribute to the success of the organization
- Participates in organizational improvement activities including patient satisfaction, Six Sigma committee, department and/or divisional teams and community activities
- Understands and applies applicable federal and state requirement
- Identify and reports compliance issues as appropriate
Requirements
- RN required
- 3 years clinical nursing (RN) experience and 1 year UR/CM/QM experience preferred
- Basic understanding of Medicare, Medicaid and managed care
- Discharge planning or home health background
- Excellent verbal and written communication skills, problem solving, critical thinking and conflict resolution.
- Graduate of an accredited School of Nursing, BSN strongly preferred.
- Licensure from the State of New Jersey as a Registered Nurse
- Case Management Certification (requirement within one year of hire beginning April 1, 2015)
Benefits
- medical/prescription, dental and vision insurance
- health and dependent care flexible spending accounts
- 403(b) (401(k) subject to collective bargaining agreement)
- paid time off
- paid sick leave as provided under state and local paid sick leave laws
- short-term disability and optional long-term disability
- colleague and dependent life insurance and supplemental life and AD&D insurance
- tuition assistance
- employee assistance program that includes free counseling sessions
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical reviewdenial managementdischarge planningmedical necessity determinationauditingdocumentationconcurrent denial managementretrospective appeal processPayer specific screening toolscase management
Soft Skills
communicationproblem solvingcritical thinkingconflict resolutionteam collaborationorganizational improvementaccountabilitypatient satisfaction
Certifications
Registered Nurse (RN)Case Management CertificationBSN