Utilization Review/Denial Specialist RN
For more than 100 years, Southern New Hampshire Medical Center has honored our mission: to improve, maintain, and preserve the overall health and well-being of individuals living in the greater Nashua area by providing information, education, and access to exceptional health and medical care services. We have literally been at the heart of better health for Greater Nashua. Our main downtown campus, a familiar landmark for generations, has grown along with the Gate City. Today, The Medical Center and our affiliated doctors and services extend across much of southern New Hampshire. Along with our growth has been the opportunity for many to build and enhance their careers within our organization. We encourage the professional and personal development of our employees and are proud of the workplace culture we have developed.
The Utilization Review/Denial Specialist RN works with the care team to evaluate medical acuity for appropriate level of care orders and documentation to facilitate insurance coverage, and proactively prevent denials. He/she ensures level of care charges are applied accurately and meet compliance within CMS and commercial insurance guidelines. He/she reviews appeal options for medical necessity insurance denials.
The minimum required to perform the essential duties of the role.
These are not required to perform the basic functions of the role.
Formal education (e.g. High School Diploma, Bachelor's degree, graduate of an accredited program)
Associate Degree Science (ADN)
Completion of BSN or higher nursing degree by 2020
Baccalaureate in nursing strongly preferred
Include due date if licensure/certification is required after hire.
Current NH Nursing License as a Registered Nurse
Number of years and type of directly related work experience (e.g. 2-4 years of accounting experience)
5 years of experience in acute care Utilization Review and/or Appeal Management. Experience in use of Interqual, Milliman or other Healthcare acute criteria.
Commonly known principles to execute the duties of this job.
CMS Regulations, Utilization Review criteria.
Measurable learnings (e.g. Intermediate level of Excel and Word)
Excellent written and verbal communication skills. Competent in Microsoft Office and general computer skills.
Demonstrated learnings(e.g. Ability to multitask and prioritize assignments)
Ability to achieve the following competencies:Within 90 days:
Assess acute medical necessity utilizing appropriate criteria
Conduct charge reviews and charge entry
Collect and trend Utilization Review data metrics
Review appeal options for commercial insurance, RAC, and QIO
medical necessity denials
Meet deadlines for the Appeal process
Regulations to meet compliance
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, disability status, veteran status, or any other characteristic protected by law.