$35.50 - $53.25
Coordination with members of the healthcare team and payors to facilitate placement of patients in the appropriate level of care related to medical necessity. Promotes an open communication between utilization management and the health care team concerning level of care. Responsible for timely provision/flow of specific clinical information to third-party payors to ensure authorization of stay.
Maintaining compliance with professional standards, national and local coverage determinations, the Centers for Medicare, and Medicaid Services (CMS) as well as state and federal regulatory requirements, as applicable. Performs admission and continued stay utilization reviews to assure the medical necessity of hospital admissions, appropriate level of care, continued stay and supportive services, and to examine delays in the provision of services, in accordance with the utilization management plan.
Demonstrates proficiency in applying nationally accepted evidence-based criteria to assure appropriate hospital level of service. Maintains timely and appropriate documentation of all utilization management activities. Utilizes critical thinking skills based upon extensive knowledge of disease processes and clinical outcomes to identify the need for further clarification of physician documentation within the medical record.
Prioritize work to facilitate timely accurate utilization management activities for each evidence-based product type. Collaborates to improve quality throughput coordination of care impacting length of stay with minimizing cost and ensuring optimum outcomes. Identification and documentation of potentially avoidable delays.
Demonstrates the ability to utilize the licensed software tool to perform and record daily medical reviews. Communicates information effectively, including comprehensive clinical information, to third-party payors, to secure timely authorization for the appropriate level of service. Provides payor feedback to case managers, social workers, and providers.
Escalates and resolves denials to secure payment for the necessary care and services provided to the patient. Collaborates with payor, physician advisor, attending provider and multi-disciplinary team to reconcile payor-issued denials. Demonstrates proficiency and knowledge of various reimbursement criteria, including documentation necessary for reimbursement from regulatory bodies.
Assist in process improvement of various committees, interdepartmental and departmental as assigned by the VP, AVP, Director, Medical Director, Manager or Team Supervisor. Supports and contributes to the Patient Centered Care Philosophy by understanding that every staff member is a Caregiver whose role is to meet the needs of the patient. Performs other duties and responsibilities as assigned and within the time frame specified.
Physical Requirements Works in an office type setting, extensive walking throughout the facility. Prolonged periods of sitting reviewing medical records and documentation. Repetitive wrist motion and occasional lifting of 10-20 pounds.
Intact sight and hearing with or without assistive devices are required. Must speak English fluently and write English in understandable terms Education, Experience and Certifications Bachelor’s in Nursing from an accredited school of nursing, required. Master's degree in business or healthcare related field, preferred.
Previous utilization review experience preferred. Current RN license or temporary license as a Registered Nurse Petitioner in the state in which you work and reside or if declaring a National License Compact (NLC) state as your primary state of residency, meet the licensure requirements in your home state; or for Non-National License Compact states, current RN license or temporary license as a Registered Nurse Petitioner required in the state where the RN works. 5 years of related nursing experience preferred.
Clinical experience within the assigned population. Extensive knowledge of disease processes and clinical outcomes. Case Management experience or background preferred.
Strong financial and analytical skills preferred. Appropriate Professional certification required within 3 years of hire and per Clinical Care Management Certification Guidelines. Additional education, training, certifications, or experience may be required within the department by the department leader.
Our Commitment to You: Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including: Compensation Base compensation listed within the listed
based on factors such as qualifications, skills, relevant experience, and/or training Premium pay such as shift, on call, and more based on a teammate's job Incentive pay for select positions Opportunity for annual increases based on performance Benefits and more Paid Time Off programs Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability Flexible Spending Accounts for eligible health care and dependent care expenses Family benefits such as adoption assistance and paid parental leave Defined contribution retirement plans with employer match and other financial wellness programs Educational Assistance Program Note: Eligibility for programs listed above may depend on your FTE or status (e.g., full-time, part-time, per diem, temporary, etc.); please ask a Recruiter for more information during an interview.
About Advocate Health Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care.
Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs.
Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.