Position Summary/Essential Duties:

Collaborates and coordinates with all members of the health care team, patient and family (or significant others) to coordinate and ensure timely and efficient delivery of required workflow, services and tasks to result in:

• Support of positive patient health care outcomes
• Increased patient/health care team outcomes and satisfaction           
• Improved inpatient throughput and appropriate length of stay 
• Improved communication, awareness and adherence to regulatory requirements associated with utilization                       
• Support for inappropriate level of care and decreased inpatient bed day denials
• Continuity and coordination of care
• Appropriate and timely authorization for level of care
• Decreased denials    
• Appropriate reimbursement
• Perform timely and accurate review, denial communications and construct appeals, including remaining current with regulatory, payer and internal requirement.
• Collaborate with physicians, UM Nurses, PAS, and other members of the Interdisciplinary team and Revenue Cycle to collect all pertinent information to support successful appeals including communication of trends and appropriate escalation to ensure appropriate resolution resulting in expected payment.
• Document appeal activity according to department standards to support accurate and timely reporting of denial and appeal status, outstanding revenue and to help identify trends (payer, physician, service, DRG, reviewer).
• Collaborate with manager and CM Data Integrity Advisor to support training, and reinforcement resulting in decreased denials.
• Conduct all CM activities with a focus on continuous quality improvement in a manner that is supportive of UHC quality initiatives and in compliance with applicable regulatory requirements. 

*This role may encounter Protected Health Information (PHI) as part of regular responsibilities.  UH employees must abide by all requirements to safely and securely maintain PHI for our patients.  Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.  

Position Summary/Essential Duties:

Collaborates and coordinates with all members of the health care team, patient and family (or significant others) to coordinate and ensure timely and efficient delivery of required workflow, services and tasks to result in:

• Support of positive patient health care outcomes
• Increased patient/health care team outcomes and satisfaction           
• Improved inpatient throughput and appropriate length of stay 
• Improved communication, awareness and adherence to regulatory requirements associated with utilization                       
• Support for inappropriate level of care and decreased inpatient bed day denials
• Continuity and coordination of care
• Appropriate and timely authorization for level of care
• Decreased denials    
• Appropriate reimbursement
• Perform timely and accurate review, denial communications and construct appeals, including remaining current with regulatory, payer and internal requirement.
• Collaborate with physicians, UM Nurses, PAS, and other members of the Interdisciplinary team and Revenue Cycle to collect all pertinent information to support successful appeals including communication of trends and appropriate escalation to ensure appropriate resolution resulting in expected payment.
• Document appeal activity according to department standards to support accurate and timely reporting of denial and appeal status, outstanding revenue and to help identify trends (payer, physician, service, DRG, reviewer).
• Collaborate with manager and CM Data Integrity Advisor to support training, and reinforcement resulting in decreased denials.
• Conduct all CM activities with a focus on continuous quality improvement in a manner that is supportive of UHC quality initiatives and in compliance with applicable regulatory requirements. 

*This role may encounter Protected Health Information (PHI) as part of regular responsibilities.  UH employees must abide by all requirements to safely and securely maintain PHI for our patients.  Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.  

Education/Expertise:

• Graduate of an accredited school of Nursing required.

           BSN preferred.

Credentials, License and/or Certifications:

• RN with current license to practice in the State of Ohio required.
• Hospital Case Management Certification preferred.

Experience & Knowledge:

• Minimum 3 years clinical experience in acute care setting required.

• 3+ years of experience in managed care or utilization review preferred.

• Must have sound clinical knowledge base of the population to be served.
• Experience with Interqual or Milliman criteria required.

Knowledge of Medicare, Medicaid and commercial payer regulations preferred

Special Skills & Equipment Knowledge:  

• Must be detail-oriented and organized, with good analytical and problem solving ability. 
• Notable client service, communication, presentation and relationship building skills required. 
• Ability to function independently and as a team player in a fast-paced environment required. 
• Must have strong written and verbal communication skills.
• Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e. printers, copy machine, FAX machine, etc.) required.

• Demonstrated ability to apply concepts, utilize sound judgment and work independently within a framework of guidelines required.

CM software proficient preferred.