[Hiring] RN Utilization Review @Highmark Health

Role Description

Responsible for obtaining insurance precertification/recertification, functioning as a liaison with third party payers, communicating clinical information to the insurance companies as requested, addressing and resolving any actual or potential denials, and functioning as a member of the care coordination team.

• Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party payer guidelines. (30%)
• Obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements. (30%)
• Documents, monitors, intervenes/resolves, and reports clinical denials/appeals and retrospective payer audit denials; collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor, and third party payers, etc. (30%)
• Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental/commercial payer guidelines. (5%)
• Adheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodies. (5%)
• Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
• Assumes responsibility for AHN required continued education and own professional growth.
• Performs other duties as assigned or required.

Qualifications

• Minimum: Bachelor’s degree or relevant experience and/or education as determined by the company in lieu of bachelor's degree
• Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)
• Nationally recognized Care Management Certification within 5 years of start date (3 years for currently employed UR's)
• 2-3 years nursing experience with 1 year in Utilization Management
• Preferred: Experience in case management, discharge planning and/or the application of InterQual criteria

Requirements

• This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
• Employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.
• Compliance with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures.
• Compliance with all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
• Adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Benefits

• Pay Range Minimum: $31.02
• Pay Range Maximum: $48.54
• Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.
• The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.