Description

　　HOW WE CARE FOR YOU:

　　At Rochester Regional Health, we are dedicated to getting healthcare right. Our robust benefits and total rewards foster employee wellbeing, professional development and personal growth. We care for your career while caring for the community.

　　Health & Wellness Benefits starting Your First Day

　　Personal Time that includes Vacation Time, Sick Time & Holidays

　　Retirement Savings Program

　　Same Day Pay through DailyPay

　　Student Loan Repayment Program

　　Tuition Assistance & Reimbursement

　　Free Parking

　　SUMMARY

　　The Utilization Management Nurse will review all inpatient medical necessity denials for the health system based on InterQual and/or CMS guidelines.

　　STATUS: Full Time

　　LOCATION: Rochester General Hospital

　　DEPARTMENT: Utilization Management

　　SCHEDULE: Monday - Friday; Days. No weekends or holidays.

　　ATTRIBUTES

　　3 years of acute hospital care, Case Management and/or Utilization Management experience

　　Current New York State Registered Nurse License

　　Excellent oral and written communication and interpersonal skills

　　Good understanding of medical management techniques and processes

　　Strong organizational and problem solving skills

　　Electronic Medical Record experience (Epic)

　　RESPONSIBILITIES

　　Patient Claims. Review standard UM sources for potential inpatient medical necessity denials. Review patient class in the event manager, assist with LOC determination retrospectively, and changes patient class as it relates to the Provider order for billing purposes.

　　Insurance Review. Prepare the UM review findings, initiate and 1st, 2nd, and/or arbitration appeals as needed. Document in all areas that an appeal has been initiated or no appeal is necessary per UM reviews. Track and monitor all denials, appeals, arbitration responses to payers/audits.

　　Compliance. Maintains accountability to hospital, state, and federal regulations, and professional standards. Initiates alternate level of care determinations in compliance with regulatory and contractual agreements.

　　PHYSICAL REQUIREMENTS: M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.

　　LICENSES/CERTIFICATIONS:

　　RN - Registered Nurse - New York State Education Department (NYSED)BLS - Basic Life Support - American Heart Association (AHA)PAY RANGE: $70,000.00 - $100,000.00

　　The listed base pay range is a good faith representation of current potential base pay for successful applicants. It may be modified in the future. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.

　　Rochester Regional Health is an Equal Opportunity / Affirmative Action Employer. Minority/Female/Disability/Veteran

　　Minimum Salary: 70000.00Maximum Salary: 100000.00Salary Unit: Yearly