Utilization Review/Quality Associate (RN)

Job Description

General Information:

Job title: Utilization Review/Quality Associate (RN)

Schedule: Full-time, 80 hours per pay period

Weekend rotation: None required

Holiday rotation: None required

Additonal Information: Remote eligible position, however, must hold an RN license per position requirements.

Position Summary:

The Utilization Review Nurse / Quality Associate position facilitates the prior authorization of managed care patients. The utilization review component of the position is the responsibility and performance of the utilization review function, ensuring compliance with mandated regulations, and having in depth knowledge of regulatory utilization review functions in a prospective payment system hospital. The quality associate role assists with assuring the continual readiness with accrediting body standards and performs a variety of complex, frequently confidential, and analytical tasks for the Quality Department.

Position Responsibilities:

Utilization Review:

Obtain prior authorization and timely insurance notification.

Communicate Provider plans to notify insurance entities.

Evaluate, and intervene, if necessary, appropriateness of admission and placement using MCG Guidelines in conjunction with documentation in the patient's medical record.

Coordinate with Hospitalist and care manager to facilitate timely discharge of patients.

Coordinate as appropriate with Denial and Appeals management, Case Manager, Patient Accounts and other necessary parties for denials, appeals, and medical necessity reviews.

Validates correct insurance information is on file. Works with registration to correct any incorrect information.

Provides financial information and resources to uninsured/underinsured patients.

Monitors for timely and accurate completion of regulatory forms that apply to role (MOON forms etc.).

Identify, analyze, and interpret data from a variety of clinical and financial sources.

Prepare reports and information for Utilization Review meetings.

Perform other duties as requested.

Quality Associate:

Complete chart reviews, data entry, and correspond with clinic staff for Clinic Insurance Programs.

Chart review and data entry for Hospital Quality Reporting Metrics.

Ongoing Professional Practice Evaluation (OPPE) data collection and monitoring.

Assist with incident reporting process and follow-up with leaders.

Assist with The Joint Commission (TJC) preparation and review of clinical department processes.

Perform other duties as requested.

Position Requirements:

Two-year degree in nursing required. Four-year degree in nursing preferred.

Must hold and maintain nursing license. RNs with an active Compact Licensure are to obtain a Wisconsin RN license within 90 days of relocation.

BLS certification required (if working on-site)

1+ years of Utilization Review work experience required.

Exceptional accuracy and attention to detail required.

Knowledge, Skills, & Abilities

Intermediate proficiency with computers is required, including Office applications.

Ability to work within the electronic medical record to interpret medical information as it relates to patient admissions.

Solid understanding of insurance system, including Medicare/Medicaid.

Excellent organization and communication skills.

Strong quantitative and analytical competency.

Self-starter with excellent interpersonal communication and problem-solving skills.

Job Posted by ApplicantPro

Full-time