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Utilization Review and Denial Management RN Supervisor

John T. Mather Memorial Hospital - Port Jefferson, NY

Utilization Review and Denial Management RN Supervisor

Shift:

8:00AM-4:00PM. * Includes some weekends and holidays.

Weekends/Holidays:

Weekends, Holidays

Qualifications:

Registered Nurse with 5 years med/surg or ED experience. BSN required. Knowledge of InterQual and Milliman guidelines. Utilization review experience preferred. Denial management preferred

Duties

Determine the medical necessity for admission or other service status using InterQual and Milliman guidelines.  Assign financial/service status (IP, OBS, D/C, Ambulatory 23hr, ED) based on medical necessity determination. Perform denial and appeal functions. Perform UR reviews. Write clinical reviews for commercial payor appeals.  Works closely with Case Management & CDI staff, HIM, Revenue Cycle and Business office. Communicates pertinent information and assists with problem identification, resolution and follow up.  Manage all IPRO/IPRA/LIVANTA quality concerns. Develop/Track and Report all UR data. Work closely with physicians regarding UR concerns and denials. Coordinate discharge appeals. Assists AVP, Medical Affairs with employee evaluations and staff schedule.

8 days 18 hours ago

John T. Mather Memorial Hospital

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Utilization Review and Denial Management RN Supervisor John T. Mather Memorial Hospital - Port Jefferson, NY, United States

   

Location: Port Jefferson, NY

Company Profile:
John T. Mather Memorial Hospital is an accredited 248-bed, non-profit community hospital dedicated to providing a wide spectrum of health care services of the highest quality to the residents of Suffolk County in a cost effective manner. As members of the Mather Hospital Family - trustees, medical staff, hospital staff, volunteers and benefactors - we are committed to providing care to the best of our ability showing compassion and respect and treating each patient in the manner we would wish for our loved ones. We will meet or exceed each patient's expectations through the continued collaborative efforts of each and every member of the Mather Hospital Family.