Utilization Management Nurse Specialist

3 weeks ago

Salt Lake, Utah, United States Myriad Genetics Full time
Job Title: Utilization Management Nurse Specialist

Job Summary:
Myriad Genetics, Inc. is seeking a skilled Utilization Management Nurse Specialist to join our team. This role will be responsible for leading and performing individual work on appeals for erroneous denials and obtaining patient chart notes. The successful candidate will have a strong background in insurance utilization management and be able to interact with clinician offices and clinicians to overcome barriers to appropriate patient care.

Key Responsibilities:
  • Understand Myriad products and their recommended use in patient populations.
  • Understand the details required to document for a payor how a patient is appropriate for coverage for the test their doctor ordered.
  • Understand insurance denial reasons on claims and prior authorizations, and insurance appeal processes for claims and prior authorizations.
  • Be a strong advocate for patients to challenge erroneous denials and obtain medical records from clinician offices.
  • Be skilled at communication during situations that can be tense and complex to prioritize appropriate patient coverage for testing ordered by their clinician.
  • Prepares and provides training for the Revenue Cycle team on how to replicate processes designed by the Nurse Advocate to challenge erroneous insurance denials and obtain medical records from clinician offices.
  • Speak to patients, when needed, to explain and understand their individual situation and how Myriad can work with them to obtain coverage for appropriate testing.
  • Assist Revenue Cycle leaders with measuring predictors of success in gaining coverage and identify root causes for denials. Coordinate payor reviews with Revenue Cycle and leaders to meet company goals to reduce unpaid tests.
  • Develops relationships with Revenue Cycle vendors to ensure vendor performance and quality meets or exceeds standards set for those relationships.
  • Drives a culture of continuous improvement that engages the Revenue Cycle Management team and participates in the Quality Assurance plan.

Qualifications:
  • RN is required.
  • 5+ years of related experience with 3+ years as a nurse reviewer at a payor required.
  • Demonstrated ability to interact with clinician offices and clinicians to overcome barriers to appropriate patient care.
  • Intermediate knowledge of Microsoft Word and Excel.
  • Working knowledge of ICD-10, CPT and HCPCS coding, HIPAA regulations, and insurance appeal procedures.

Physical Requirements:
Lifting Requirements - light work or exerting up to 20 pounds of force frequently. Physical Requirements - stationary positioning, moving, operating, ascending/descending, communicating, observing, pushing or pulling, and reaching. Use of equipment and tools necessary to perform essential job functions.

EEO:
We recognize that our people are our strength and the diverse talents they bring to our global workforce are directly linked to our success. We are an equal opportunity employer and place a high value on diversity and inclusion at our company. In hiring and all other employment decisions, we prohibit discrimination and harassment on the basis of any protected characteristic, including race, religion, color, national origin, gender, sexual orientation, gender identity, gender expression, age, marital or veteran status, pregnancy or disability, or any other basis protected under applicable law. In accordance with applicable law, we make reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as any mental health or physical disability needs.

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