This position conducts concurrent retrospective reviews for clinical, financial, resource utilization. Coordinates with Healthcare team to achieve optimal efficient outcomes, decreasing length of stay (LOS) and avoiding delays/denied days. Helps drive change by identifying areas of performance improvement (e.g., day to day workflow, education, process improvements, patient satisfaction). Is accountable for a designated caseload and provides intervention, coordination to decrease avoidable delays/denial of payment resources. Specific functions include: Facilitation of pre-certification and payer authorization processes, Screens pre-admission and admission process by using established criteria for all points of entry, Facilitates communication between payers, review agencies and health care team. Identifies delays in treatment or appropriate utilization and serves as a resource, application of process improvement methodologies in evaluating outcomes of care. Coordinating communication with physicians and identifies opportunities for expedited appeals and collaborates to resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments Access Management and other members of the healthcare team to ensure timely communication to payers. Estimated salary range for this position is $79331.20 - $103130.56 / year depending on experience.

Degrees:

• Bachelors.

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Remote Customer Support, $50/hr, Night Shift, No Degree
Remote Data Entry, $40/hr, College Student Friendly, Part-Time
Live Chat Support, $42/hr, Weekend, Remote, No Degree
Virtual Assistant, Remote, $45/hr, Evening, No Experience
Remote Phone Job, $50/hr, College Student, Night Shift
Remote Moderator, $42/hr, Weekend, No Experience Required
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Customer Support, $50/hr, Remote, Evening/Night Job, No Degree
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Remote Data Entry, $40/hr, Part-Time, No Degree Required
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Licenses & Certifications:

• MCG Care Guidelines Specialist.
• ANCC Nursing Case Management.
• ANCC Nurse Executive, Advanced Certification.
• ANCC Nurse Executive - Board Certified.
• AAMCN Utilization Review Professionals.
• McKesson Certified Professional in Utilization Management.
• NAHQ Certified Professional in Healthcare Quality.
• NACCM Care Manager Certified.
• ACMA Case Management Administrator Certification.
• ACMA ACM Certification.
• Registered Nurse.
• CCMC Case Manager.

Additional Qualifications:

• RNs hired prior to 2-2012 (10/1/2017 at Bethesda or 7/1/2019 at BRRH) with an Associates Degree in Nursing are not required to have a BSN to continue their non-leadership role as an RN.
• However, they are required to complete the BSN within 5 years of job entry date.
• RN license, MCG Specialist Certification-SCG/GCR and one of the listed certifications required.
• 3 years of Nursing experience preferred with 2 years of hospital or payor utilization management experience required.
• Excellent written, interpersonal communication and negotiation skills.
• Strong critical thinking skills and the ability to perform clinical chart review abstract information efficiently.
• Strong analytical, data management and computer skills.
• Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
• Current working knowledge of payer and managed care reimbursement preferred.
• Ability to work independently and exercise sound judgment in interactions with the health care team and patients/families.
• Knowledgeable in local, state, and federal legislation and regulations.
• Ability to tolerate high volume production standards.

 

Case Management/Home Health