Rn Utilization Review- Appeals Coordinator

3 weeks ago

Baltimore, United States MEDSTAR HEALTH Full time

Reviews and evaluates external denials for medical necessity. Coordinates and monitors the preventive denial and appeals process. Collaborates with the physician, nurse manager, and other members of the health care team to meet individualized patient outcomes. Performs pre-admission, concurrent, and retrospective medical record reviews based on approved screening criteria, knowledge of insurance coverage, and communication with the third-party payers. May assist the manager in managing the daily departmental operations with the goal of maintaining adequate staffing levels and efficient workflow. May act as a resource and mentor to the Utilization Review staff.

**Education**
- Valid RN license in the State of Maryland required and
- Bachelor's degree in Nursing preferred

**Experience**
- 5-7 years Clinical experience. 5 years experience in utilization management and appeals decision and writing required and
- 5-7 years Experience in utilization management and appeals decision and writing and case management quality management or discharge planning experience. preferred

**Licenses and Certifications**
- Certification in Utilization Review, Case Management, and Health Care Quality Upon Hire preferred and
- If MFM, Maternal Fetal Medicine (MFM) coding and billing yearly seminars Upon Hire preferred and
- RN - Registered Nurse - State Licensure and/or Compact State Licensure in the State of Maryland Upon Hire required

**Knowledge, Skills, and Abilities**
- Excellent verbal and written communication skills.
- Completes appeal process for denied days for medical necessity that meets Interqual criteria, or appear to be clinically justified.
- Completes evaluation of all external denials for medical necessity received by the hospital.
- Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.
- Coordinates decision making regarding the feasibility of initiating an appeal for each external denial for medical necessity.
- Develops medical summaries of denied cases for review by hospital administration and for possible legal/Maryland Insurance Administrative (MIA) action, where indicated.
- Identifies and implements strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials.
- Identifies system delays in service to improve the provision of efficient and timely patient care. Identifies process issues related to the concurrent Case Management system, including appropriate resource utilization and identification of avoidable days.
- Maintains records of concurrent and retrospective denial activity in conjunction with Case Management support staff. Monitors and tracks denials and appeal results, and coordinates information with Patient Financial Services (PFS). Reports data to the Director and Operations Review Committee.
- Meets with attending physicians and Physician Advisor, as appropriate, to clarify or collect information in the process of development of appeal letters.
- Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required.
- Participates in the educational process for physicians and hospital staff to address issues that impact the number and type of denials. Serves as a resource to all staff in areas of utilization review/management.
- Utilizes and analyzes current medical/clinical information as well as medical record information to complete appeal letters.
- May interact with and assist third party payer reviewers to facilitate appropriate care and ensure payment of services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources.
- May utilize research methods to collect, tabulate, and analyze data in collaboration with the medical staff, and hospital performance improvement initiates. Implements strategies to correct or modify trends seen through data analysis and outcome monitoring.
- May serve as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, orientation and formal educational offerings.
- May manage the department in the Managers absence. Keeps Manager informed about issues related to staffing and problem areas. Keeps Manager informed about issues related to quality, risk, patient/family issues and concerns, allocation of resources and vendor/payer issues. Oversees the orientation of new UR Coordinators by establishing the plan and monitoring progress in conjunction with other staff, as necessary. Assists the Manager in monitoring performance issues. Contributes to the performance evaluation process by providing feedback to the Manager and assisting the creation of professional development plans for UR Coordin

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