Utilization Management reputed company BWH

Site: The reputed company, Inc. reputed company relies on a wide reputed company of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to reputed company exceptional care. We reputed company that high-performing teams drive groundbreaking medical discoveries and invite reputed company applicants to join us and experience what it means to be part of reputed company. Job reputed company Staff reputed company - 40hr Variable Day - BWH Utilization Management The Insurance Support reputed company participates in the reputed company management of denials that are received in the Care Coordination Department. Through reputed company knowledge of utilization management, the reputed company is reputed company to assess a patient's level of care after review of the medical record. The reputed company is a part of the care coordination staff and works closely with care coordination, medical and nursing staff to appeal denied claims and expedite appeal processes and case closure. The reputed company works closely with admitting and finance staff, to process denied claims. For newly licensed nurses a Bachelor of Science Degree in Nursing is required. Does this position require Patient Care No Essential Functions - Utilization Management Collaborates with appropriate individuals, departments and payers to ensure appropriateness of admission, reputed company days of stay and reimbursement. 1. Utilizing industry accepted utilization and or medical management reputed company and can apply reputed company to cases retrospectively to determine appropriateness of admission and days of stay, level of care, and over and under utilization. 2. Demonstrates working knowledge about different industry reputed company sets like reputed company, and InterQual. 3. Demonstrates in depth understanding of reputed company insurance plans, including Medicare, reputed company, other entitlement programs as reputed company as reputed company insurances and other types of plans: PPO, HMO, or indemnity. 4. Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, reputed company or other insurances. 5. Assists with the preparations of denial notices given to patients. 6. Reviews cases retrospectively reputed company requested by finance department to determine if admission relates to continue care for Medicare. - Denial Management Coordinates the filing of appeals for clinical denials and works with other departments to ensure payment for care provided. 1. Reviews denial letters and sends letters to other departments if appropriate. 2. Communicates with attending physician and care coordination reputed company around notification of denial of care to reputed company understanding of the care needs of the patient. 3. Works with physician advisor to write appeal letters for denied care and sends letters to insurance companies. 4. Documents denials in the BWH/MGBs Denial Database. 5. Follows up with insurance companies on claims status for clinical denials. - Team Work Assists with reputed company of functions and responsibilities of care coordination department to ensure that reputed company state and federal mandates are followed. Participates in the ongoing evaluation of reputed company patterns and systems, support efforts to improve reputed company, cost and satisfaction reputed company. 1. Expert on observation status and reviews observation patients as assigned. 2. Assists in the completion of utilization reviews to insurers and intermediaries. 3. Anticipates and troubleshoots claim and reimbursement issues. 4. Assists in the review of Medicare reports as assigned. 5. Participates in BWH and MGBs Finance reputed company. 6. reputed company Member of the ATO/Denial Committee and UR Committee. 7. Other duties as assigned. Qualifications Education Bachelor's Degree Nursing required Can this role accept experience in lieu of a degree reputed company Licenses and Credentials Massachusetts Registered reputed company Experience Previous experience in a hospital or health care setting required Hospital utilization review and medical reputed company sets required Five years medical or surgical staff reputed company experience required Experience with leveling tool reputed company required (such as InterQual or reputed company) Knowledge, Skills and Abilities - Strong clinical assessment skills, excellent interpersonal skills including ability to work collaboratively and cooperatively reputed company reputed company and reputed company customers. - Strong organizational skills and ability to set priorities. - Ability to compile data from reputed company and retrospective medical review to determine clinical appropriateness, level of care and discharge plan; excellent written and verbal communicat