Nurse for Utilization Management Services

2 weeks ago


Nashville, Tennessee, United States Nashville General Hospital Full time


Nashville General Hospital is seeking a Nurse for Utilization Management on a PRN Basis

The Nurse in Utilization Management will oversee the Prior Authorization process for all ancillary services and procedures conducted at the Hospital or in Clinics. This role involves coordinating 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 verify authorizations obtained from external providers and institutions, and will obtain retroactive authorizations when modifications to tests or procedures are required. Collaboration with contracting is essential to secure Single Case Agreements when necessary. Documentation of authorizations will be performed in conjunction with our claims and billing contractors. The nurse will manage the in-house authorization process for Observation/Inpatient hospital stays and will review Observation cases for potential conversion to Inpatient status. Communication with hospital teams regarding conversion and authorization is crucial. Additionally, the nurse will assist in tracking and trending denials and weekly unbilled claims. *This position requires working 4 weekend days each month (4-8 hour shifts) along with 1 summer and 1 winter holiday. There is potential for additional shifts on a weekly basis as well.*

Key Responsibilities of the Utilization Management Nurse:
  • Review daily schedules to identify tests, procedures, and appointments requiring authorization.
  • Contact insurance companies to obtain Prior Authorization through phone, fax, or online portals.
  • Document results of prior authorization requests.
  • Coordinate with the ordering office, practitioner, and performing department when additional information is required for authorization or in cases of denial.
  • Communicate with external providers or institutions when authorization is found to be inactive or has not been obtained when necessary.
  • Engage in discussions regarding denials and unbilled claims to identify barriers and reduce occurrences of denial.
  • Review daily census for authorization needs.
Required Skills & Qualifications:
  • Graduation from an accredited nursing program.
  • Possession of an active license to practice as a registered nurse in the state of Tennessee.
About Nashville General Hospital

Nashville General Hospital (NGH) is Nashville's original community-based hospital. Joint Commission accredited, NGH accommodates a diverse range of needs from emergency services and acute care to ancillary and ambulatory services. NGH remains committed to addressing the healthcare needs of Nashville and Davidson County's underserved populations while providing care to all community segments.

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.
Nashville General Hospital is an Equal Opportunity Employer/Disability/Veteran.

We are an E-Verify employer.

For more information, please click on the following links:
E-Verify Participation Poster: English Spanish
E-Verify Right to Work Poster: English Spanish

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