Top 5301 Rn Utilization Review Jobs

Clinical Review and Appeals Specialist
Life Care Centers of America —Cleveland, TN
- Weekends as needed
- Nursing
- RN License
- Customer service
- Health insurance
- Dental insurance
Quick Apply
RN Director of Care Management - Sign-On Bonus Eligible
Merit Health River Region —Vicksburg, MS
- Full-time
- Nursing
- RN License
- Hospital
- Relocation assistance
- Health insurance
Quick Apply
MDS Coordinator, RN
Confidential —Spartanburg, SC
- Full-time
- Background check
- Anatomy knowledge
- Skilled nursing facility
- Free parking
- Disability insurance
Quick Apply
Clinical Reimbursement & Utilization Coord
St Camillus Residential Health —Syracuse, NY
- $24 - $30 an hour
- Full-time
- Mid-level
- Case management
- LPN
- Free parking
- Dental insurance
Quick Apply
3d
TOP Case Management Program Manager
International SOS —San Antonio, TX
- Background check
- Nursing
- RN License
Quick Apply
Director of Utilization Review/Management
River Oaks Hospital —New Orleans, LA
- Full-time
- Background check
- Nursing
- RN License
- Health insurance
- Dental insurance
Quick Apply
Utilization Review RN
Providence Health and Services —Portland, OR
- $50.14 - $77.83 an hour
- Part-time
- Nursing
- RN License
- Mid-level
- Paid parental leave
- Paid holidays
Utilization Management Nurse
TEXAS INDEPENDENCE HEALTH PLAN INC —Austin, TX
- Weekends as needed
- Hybrid work
- Nursing
- Microsoft Excel
- Microsoft Outlook
Quick Apply
Registered Nurse (RN)
P.I.E. Management, L.L.C. —Detroit, MI
- $64 an hour
- Full-time
- Nursing
- RN License
- Adults
- Health insurance
- Dental insurance
Quick Apply
11d
Nurse Case Manager, Utilization Management
1199SEIU Family of Funds —New York, NY
- $89,400 - $106,100 a year
- Full-time
- Nursing
- RN License
- Mid-level
Utilization Review (UR) Coordinator - Per Diem
Meridell Achievement Center —Liberty Hill, TX
- Part-time
- Background check
- LMFT
- Nursing
- Health insurance
- Dental insurance
Quick Apply
2d
Utilization Review Nurse
HAMASPIK CHOICE INC —Spring Valley, NY
- $45 - $47 an hour
- Full-time
- Nursing
- RN License
- Mid-level
Quick Apply
Utilization Review RN
Memorial Health —Springfield, IL
- $32.95 - $52.73 an hour
- Full-time
- Acute care
- Nursing
- RN License
Utilization Review Manager
Forest View Hospital —Grand Rapids, MI
- Full-time
- Management
- Psychiatry
- RN License
- Continuing education credits
- Health savings account
Quick Apply
Utilization Review Director
Aspen Grove Behavioral Hospital —Orem, UT
- Full-time
- Background check
- Master of Social Work
- Nursing
- Free parking
- Health savings account
Quick Apply
RN Assessment Manager (Temporary)
TAG MedStaffing —Bronx, NY
- $62 an hour
- Temporary
- Nursing
- RN License
- Customer service
- Health insurance
- Paid time off
Quick Apply
3d
RN Inpatient Hospital Auditor | Remote | Contract
Walker Healthforce, LLC —Newark, NJ
- $25.00 - $35.81 an hour
- Contract
- Anatomy knowledge
- RN License
- Mid-level
- Health insurance
- Dental insurance
Quick Apply
Utilization Specialist
RiverWoods Behavioral Health —Riverdale, GA
- Part-time
- CPR Certification
- Nursing
- RN License
Utilization Management- RN
South Country Health Alliance —Medford, MN
- $34.39 - $47.94 an hour
- Weekends as needed
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Disability insurance
- Health insurance
3d
Staff Nurse - Case Manager
Skagit Regional Health —Mount Vernon, WA
- $40.54 - $73.92 an hour
- Full-time
- Nursing
- RN License
- Hospital
- Disability insurance
- Health insurance
Quick Apply

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Clinical Review and Appeals Specialist

Life Care Centers of America -
Cleveland, TN

Quick Apply

Job Details

Full-time

Benefits

Health insurance
Dental insurance
401(k)
Paid time off
Employee assistance program
Vision insurance
Life insurance

Qualifications

Confidential information handling
Long-term care regulations
Medicare
RN License
HCQM Certification
Employee relationship building
English
Medicare regulations
Team management
Clinical outcome improvement
Productivity software
Clinical quality assurance standards
Healthcare compliance
Quality assurance experience within healthcare
Implementing nursing quality improvement initiatives

Full Job Description

Clinical Review and Appeals Specialist
Life Care Centers of America
Cleveland, TN

Position Summary

The Clinical Review and Appeals Specialist timely reviews audit requests and denied claims from all payors related to medical necessity, appropriate setting/status determination, authorizations, and appropriate length of stay. Ensures all audits and/or denied claims are accurately worked and appealed to obtain maximum reimbursement and minimize recoupment in accordance with all applicable laws, regulations, and Life Care standards.
Reports to Director of Clinical Review and Appeals

Working Conditions

Works in office setting as well as facility sites (e.g., division office, off-site venues, facilities)
Subject to frequent interruptions
Involved with patients, associates, visitors, government agencies/personnel, etc. under all conditions and circumstances
Subject to hostile and emotionally upset patients, family members, etc.
Works beyond normal working hours, on weekends and holidays, and in other positions temporarily as necessary
Subject to falls, burns from equipment, odors, etc. during facility visits

Education, Experience, and Licensure/Certifications

Must have Registered Nursing (RN) degree (RN) from an accredited college or university
Must be currently licensed/registered in applicable state. Must maintain an active Registered Nursing (RN) license in good standing throughout employment
Or must have minimum an Associate’s/Bachelor’s degree from accredited PT/PTA or OT/OTA program OR minimum Master’s degree from SLP program
May have a certification in Healthcare and Quality Management (HCQM)
Must have extensive knowledge of the RAI process, Medicare regulations, Quality Measures, and PDPM
Must have experience in managing multiple people and facilities
Certification in HealthCare Compliance (CHC) preferred
Must have knowledge of the Quality Reporting Program

Specific Requirements

Must be willing and able to travel, including air travel
Must be proficient in Word, Excel, and e-mail
Must have excellent verbal and written communication skills
Must maintain a positive attitude and positive communication supporting Life Care goals and initiatives
Must be able to follow directions of supervisor
Must communicate and function productively with associates at the facility, regional, and division levels
Must possess the ability to make independent decisions when circumstances warrant such action
Must be knowledgeable of nursing practices and procedures as well as the laws, regulations, and guidelines governing nursing functions in the post-acute rehab and long-term care facility
Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the Clinical Services department
Must perform proficiently in all applicable competency areas (See position competencies for additional details)
Maintains professional working relationships with all associates, vendors, etc
Maintains confidentiality of all proprietary and/or confidential information
Must understand and follow company policies including harassment and compliance procedures
Displays integrity and professionalism by adhering to Life Care’s Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training

Essential Functions

Must be able to effectively direct the management of clinical and/or rehabilitation denials in accordance with Federal guidelines and company benchmarks
Must be able to implement a denial prevention program that focuses on documentation quality: manage denial process to achieve benchmarks
Must be able to collect, review and analyze current audit data. Must be able to identify trends and initiate clinical quality improvement initiatives, focus on improving clinical quality indicators, outcomes, and financial metrics
Must be able to oversee collection and utilization of operational and benchmarking data to recommend and set targets for improvement based on research of industry best practices and recommending process improvements
Must be able to stay current with any reimbursement or MDS and Rehab updates and provide education opportunities when needed
Must be able to provide education as needed regarding updates or changes to the CMS RAI Manual or Skilled Nursing Facility Regulations that impact reimbursement
Must be able to serve as subject matter expert for appeals and denials and as a resource for clinical services team and provide education to promote reduction in denials
Must be able to answer questions related to audits and appeals
Must be able to develop tracking systems to provide accurate audit and denial data
Must be able to document and log audit and appeal data timely
Must be able to complete clinical review of appropriate pre- and post-claim denials.
Must be able to prepare clinical discussions and appeal letters for appeal
Must be able to ensure submission of appeals to the payors within allotted time frames to prevent fiscal penalties
Must be able to assist clinical corporate with development of policies, procedures, education modules, and other training materials, related to coding, denials and accurate billing, when requested
Must be able to complete compliance review to include researching and supporting questions related to Federal guidelines and state practice acts
Must be able to serve as therapy liaison with Compliance, Medicare Claims and IT
Must be able to serve as link between Therapy and Compliance related to coding issues and initiatives and ensures accurate ICD-10 and HCPC coding
Must exhibit excellent customer service and a positive attitude
Must be able to assist in the evacuation of patients
Must demonstrate dependable, regular attendance
Must be able to concentrate and use reasoning skills and good judgment
Must be able to communicate and function productively within an interdisciplinary team
Must be able to sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours
Must be able to read, write, speak, and understand the English language
Must be able to lift weight as deemed appropriate for the position

An Equal Opportunity Employer

Job Type: Full-time

Benefits:

401(k)
Dental insurance
Employee assistance program
Health insurance
Life insurance
Paid time off
Vision insurance

Ability to Commute:

Cleveland, TN 37312 (Required)

Ability to Relocate:

Cleveland, TN 37312: Relocate before starting work (Required)

Work Location: In person

Quick Apply

Refine Your Search

Rn Utilization Review jobs

Clinical Review and Appeals Specialist

RN Director of Care Management - Sign-On Bonus Eligible

MDS Coordinator, RN

Clinical Reimbursement & Utilization Coord

TOP Case Management Program Manager

Director of Utilization Review/Management

Utilization Review RN

Utilization Management Nurse

Registered Nurse (RN)

Nurse Case Manager, Utilization Management

Utilization Review (UR) Coordinator - Per Diem

Utilization Review Nurse

Utilization Review RN

Utilization Review Manager

Utilization Review Director

RN Assessment Manager (Temporary)

RN Inpatient Hospital Auditor | Remote | Contract

Utilization Specialist

Utilization Management- RN

Staff Nurse - Case Manager

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