RN Utilization & Denial Management Specialist

Virtua Health; New Jersey; On-site; USD 80,000 - 124,000; Full time

Job summary

Virtua Health is seeking a Registered Nurse with 3+ years of clinical experience to support utilization management and denial processes. You will collaborate with UR Tech and AA to ensure medical necessity, discharge planning, and efficient revenue cycle operations.

Responsibilities include applying payer screening tools, consulting with Physician Advisors, documenting reviews, and contributing to quality metrics and compliance.

Qualifications

• RN required.
• 3 years clinical nursing (RN) experience preferred.
• Basic understanding of Medicare, Medicaid and managed care.
• Discharge planning or home health background.
• Excellent verbal and written communication skills, problem solving, critical thinking and conflict resolution.

Responsibilities

• Utilizes payer specific screening tools to assist in determining level of service and medical necessity.
• Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues.
• Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers.
• Appropriate and complete documentation of clinical review and denial management in the case management documentation system and in the billing system.
• Manages the concurrent denial process by referring to appropriate resource for concurrent and retrospective appeal activity process.
• Prepares and facilitates audits using appropriate screening tools and documentation.
• Accountable to job specific goals, objectives and dashboards which contribute to the success of the organization.
• Participates in organizational improvement activities including patient satisfaction, Six Sigma committee, department and/or divisional teams and community activities.
• Understands and applies applicable federal and state requirement.
• Identify and reports compliance issues as appropriate.

Job description

Virtua Health is seeking a Registered Nurse with 3+ years of clinical experience to support utilization management and denial processes. You will collaborate with UR Tech and AA to ensure medical necessity, discharge planning, and efficient revenue cycle operations.

Responsibilities include applying payer screening tools, consulting with Physician Advisors, documenting reviews, and contributing to quality metrics and compliance.