Utilization Review RN — Denials & Appeals Specialist

Capital Health Screening Centre; Rockford (IL); On-site; USD 87,000 - 120,000; Full time

Benefits offered by this job

Medical Plan

Dental Plan

Vision Plan

Retirement Savings Plan

Paid Time-Off Program

Job summary

Capital Health is a leader in patient care with expertise in utilization review, case management and clinical audits. The role focuses on inpatient utilization review for reimbursements, denials, appeals and quality improvement activities within a 40-hour workweek.

Minimum RN education with at least five years of nursing experience and three years in case management are required. Proficiency in UR software and EMR systems is expected for accurate review and reporting.

Qualifications

• Graduation from an accredited School of Registered Nursing.
• Five years' experience in nursing.
• Three years' experience in case management including utilization review, discharge planning, outcomes management, assessment, care planning, and/or care coordination.

Responsibilities

• Performs Utilization Review for third party reimbursement, denials, appeals and clinical audits for inpatient cases.
• Ensures responsibility for Performance Improvement and Quality Improvement activities.
• Prepares and submits appeals timely and ensures completion of UR inpatient appeal process.

Skills

Utilization review

Discharge planning

Care coordination

CMS guidelines

Clinical audits

Education

RN – Registered Nurse

Tools

UR software

EMR software

Microsoft Word/Excel/Outlook

Job description

Capital Health is a leader in patient care with expertise in utilization review, case management and clinical audits. The role focuses on inpatient utilization review for reimbursements, denials, appeals and quality improvement activities within a 40-hour workweek.

Minimum RN education with at least five years of nursing experience and three years in case management are required. Proficiency in UR software and EMR systems is expected for accurate review and reporting.