Nurse for Utilization Management
2 weeks ago
Nashville General Hospital is seeking a Utilization Management Nurse on a PRN Basis
The Utilization Management Nurse will oversee the Prior Authorization process for all ancillary services and procedures conducted at the Hospital or in Clinics. This role involves collaboration with procedural areas, clinics, physicians, and insurance providers to ensure that necessary authorizations are secured prior to scheduled tests or procedures. The nurse will also be responsible for verifying authorizations obtained by external providers and institutions, as well as obtaining retroactive authorizations when changes in tests or procedures occur. Additionally, the nurse will work with contracting to secure Single Case Agreements as needed and document authorizations in conjunction with our claims and billing contractors. The position also includes managing the in-house authorization process for observation and inpatient hospital stays, reviewing observation cases for potential conversion to inpatient status, and communicating with hospital teams regarding these conversions and authorizations. Furthermore, the nurse will aid in tracking and trending of denials and weekly unbilled claims. *This position requires working 4 weekend days a month (4-8 hour shifts) along with 1 summer and 1 winter holiday. There is potential to work 1-2 shifts a week as well.*
As a Utilization Management Nurse, your responsibilities will include:
- Reviewing daily schedules to identify tests, procedures, and appointments requiring authorization.
- Contacting insurance companies to obtain prior authorization via phone, fax, or online portals.
- Documenting results of prior authorization requests.
- Coordinating with the ordering office, practitioner, and performing department when additional information is required for authorization or when authorization is denied.
- Communicating with external providers or institutions when authorization is not found to be active or has not been obtained when necessary.
- Participating in discussions regarding denials and unbilled claims to eliminate barriers and reduce denials.
- Reviewing daily census.
- Graduate of an accredited nursing program.
- Active license to practice as a registered nurse in the state of Tennessee.
Nashville General Hospital (NGH) is Nashville's original community-based hospital. Joint Commission accredited, NGH accommodates a wide range of needs from emergency services and acute care to ancillary and ambulatory services. NGH maintains a strong commitment to the healthcare needs of Nashville and Davidson County's underserved populations while providing care to all segments of the community.
Our benefits include:
- Metro Health Incentive Program - Access to high-quality healthcare without incurring out-of-pocket expenses.
- Flexible Spending Accounts.
- Free parking for all employees.
We are an E-Verify employer.
For more information, please refer to the following links:
E-Verify Participation Poster: English Spanish
E-Verify Right to Work Poster: English Spanish
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