[Hiring] RN-Utilization Management and Denials Liaison @SSM Health

Role Description

Serves as the Utilization Management system-wide point of coordination between regional clinical and operational team leaders, physician liaisons, and revenue cycle leaders.

• Serves as the direct resource for the regional physician liaisons regarding Utilization Management (UM) initiatives and regional specific UM issues.
• Performs audits on UM denial write off accounts to ensure accurate categorizing of the root cause of denial and to identify potential opportunities for claims re-bill.
• Collaborates with Managed Care Organization (MCO) team members to stay abreast of contractual updates to develop and maintain UM payer grids with contractual requirements.
• Serves as a UM subject matter expert on state and federal regulatory requirements related to UM processes.
• Represents the system UM team on committees and work groups as assigned by leadership.
• Presents critical messages and complex information and reports to UM leadership.
• Provides responses to questions and concerns raised by physician liaisons, clinical and operational team members, providers, and UM leaders.
• Supports UM leadership and collaborating teams and providers with resources, data, and education to improve UM outcomes.
• Applies the existing body of evidence-based practice and scientific knowledge in health care to medical-surgical nursing practice, ensuring that nursing care is delivered based on patient’s age-specific needs and clinical needs as described in the department's Scope of Service.
• Performs other duties as assigned.

Qualifications

• Graduate of accredited school of nursing or education equivalency for licensing.
• Two years' acute nursing experience.
• Four years of Utilization Management experience.

Requirements

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.

Benefits

• Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE).
• Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.
• Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members.