Top 8 Utilization review nurse Jobs in Rock Hill, Sc

Utilization Review RN Appeals Specialist
CaroMont Health —Gastonia, NC
- Full-time
- Nursing
- RN License
- Hospital
Utilization Specialist
Rebound Behavioral Health —Lancaster, SC
- PRN
- CPR Certification
- Nursing
- RN License
RN Care Manager - Charlotte Market
ArchWell Health —Charlotte, NC
- Full-time
- Nursing
- RN License
- Mid-level
Nursing Supervisor - Registered Nurse - ER
Jobw —Rock Hill, SC
- $83,591.74 - $120,325.54 a week
- Full-time
- Medication administration
- Patient monitoring
- RN License
- Travel reimbursement
- Free parking
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Assistant Director of Nursing, RN
Windsor Run by Erickson Senior Living —Matthews, NC
- $100,000 - $115,000 a year
- 18 years or older
- Nursing
- RN License
- Health insurance
- Dental insurance
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Education: Graduate of an accredited school of nursing with a current state license as a registered nurse. As a registered nurse on our team, you’ll evaluate…
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Carolina Asthma & Allergy Center —Charlotte, NC
Other Requirements: *Current state registered nurse license. Provides patient care based on practice guidelines, standards of care, and federal/state laws and…
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Case Manager (RN) - Full-Time
OhioHealth Rehabilitation Hospital —Columbus, OH
Current Licensure per state guidelines in clinical or related discipline OR a Bachelor's or Master's in a health or human services discipline.
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Utilization Review Specialist - Autism
Nationwide Children's Hospital —Columbus, OH
Bachelor’s Degree in Social Work, Psychology, or related field, required. Documents all case reviews and maintains accurate records of all clinical activities…

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Utilization Review RN Appeals Specialist

CaroMont Health -
Gastonia, NC

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Job Details

Full-time

Qualifications

Appeals
Medicare
RN License
Writing skills
CMS regulatory compliance
Case appeal in utilization management
Bachelor's degree
Medicare regulations
Centers for Medicare and Medicaid Services (CMS)
Health record chart audits
Resource utilization in healthcare
Medicaid regulations
Regulatory compliance analysis
Insurance claims appeal handling

Full Job Description

Job Summary: The Clinical Appeals Specialist is responsible for managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Where warranted, the Clinical Appeals Nursing Specialist will write sound, compelling factual arguments in order to recoup revenue. This position also facilitates collaboration between the Utilization Review Specialist's, Medical Staff, Physician Advisor, Nursing staff, Commercial Payers, VA, Managed Medicare Organizations, Medicare, and Medicaid (Center for Medicare/Medicaid Services) to ensure correct admission status as dictated by medical necessity criteria for correct reimbursement for level of care provided and to ensure that any denial is thoroughly reviewed and that an appeal letter, if warranted, is well written and submitted in a timely manner. In addition, the following are essential duties and responsibilities of the Nurse Reviewer: Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is warranted. Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted. Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments. Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Discuss documentation-related, level of care decisions, and clinical issues with physicians and other appropriate staff. Ensure compliance with HIPAA regulations, to include confidentiality, as required. Other duties as assigned. Works closely with the Utilization Review Specialists to ensure that concurrent medical necessity is achieved. Additionally, works with outside surgical offices when called upon, to provide Medicare Inpatient Only List knowledge to ensure that surgical procedures are correctly called in and billed appropriately.

Qualifications: Bachelor's degree from an accredited college with a strong clinical background, MSN preferred. Current state-issued RN license. Minimum of three years experience in clinical area, with project experience and clinical data support preferred. 1 year appeal writing experience is required. Knowledge in areas such as InterQual Level of Care Criteria as well as knowledge of third party payer regulations related to utilization and quality review is also preferred. Must have excellent oral communication and organizational skills. Must have excellent writing skills. Previous experience with clinical resource utilization analysis, auditing, appeal writing, and chart review. Knowledge of state and federal regulations in regard to Medicare and Quality Management activities is a must. . Certification is required within one year of hire.

EOE AA M/F/Vet/Disability

Location: CaroMont Health · Utilization Review
Schedule: Full Time, 8:30am-5:00pm

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utilization review nurse jobs in rock hill, sc

Utilization Review RN Appeals Specialist

Utilization Specialist

RN Care Manager - Charlotte Market

Nursing Supervisor - Registered Nurse - ER

Assistant Director of Nursing, RN

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