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Registered Nurse (RN) Utilization Review

Fort Lauderdale, FL, United States

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Description

SHIFT: PRN

SCHEDULE: PRN/Per Diem

Marketing Coordinator - Appeals/Denials (PRN FTE .001)

(Every other Saturday)

Location- Lawnwood Regional Medical Center, Ft. Pierce

HCA East Florida Division

JOB SUMMARY:

  • The Market Denial Coordinator will be actively engaged in all levels of effective denial management for each of the Markets: reviewing all incoming concurrent denials timely and effectively and challenging them appropriately.
  • The Market Denial Coordinator will have a thorough understanding of contractual language and have strong communication skills to challenge concurrent denials with the insurance plans.
  • The Market Denial Coordinator will work closely with the Division Appeal and Denials Manager as well as Case Management, Physician Advisors, Chief Medical Officers, and External Physician Advisors, and insurance reviewers/supervisors to systematically and effectively follow through on all concurrent denials.
  • The Market Denial Coordinator will also work with the SSC Appeal Department and actively participate in reviewing the root causes of denials which resulted in a pre-write off status to prevent denial write offs.
  •  Work closely with facility Utilization Management staff as well as facility Case Management Discharge Planners to ensure support notes in Midas are completed accurately as they relate to discharge delays, DME, HH, etc. as outlined in the Denial Challenge Checklist
  •  Continuous monitoring of facility Remote Payor Mailboxes in all Markets to ensure timely follow through on all incoming denials at every facility
  •  Work independently as well as collaboratively with the other Market Denial Coordinators to ensure complete and timely follow through on all concurrent denials at every facility
  •  Become a subject matter expert on contract language as they pertain to denials: notification, Utilization management, discharge planning, and the issuance of a denial
  •  Become subject matter expert on InterQual criteria and apply that knowledge when reviewing denials for medical necessity
  •  Challenge all denials appropriately: contractual challenge versus medical necessity
  •  Utilize the Denial Challenge Checklist to ensure appropriate follow through on all concurrent denials
  •  Utilize the Denial Workflow to ensure appropriate follow through on all concurrent denials
  •  Contact Plan nurse reviewers to discuss and challenge denials issued as appropriate and to escalate to the Plan Directors, Mangers, and supervisors when applicable
  •  Work closely with the Physician Advisors, ACMO, and CMO’s at each of the facilities as well as EHR to challenge and overturn denials based on medical necessity
  •  Document denials in Midas per Cert Entry Healthstream 2014 Corporate Case Management education

Qualifications

Qualifications:

Bachelors degree preferred RN with current Florida license Required

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Facility: HCA Healthcare
Job ID: 25502-6644
Category: Supervisors Team Leaders and Coordinators
Contract: PRN/Per Diem
Shift: PRN
Job Class: PRN

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