Job description

Networks Connect Professional Staffing is conducting a search on behalf of our client, one of the fastest growing Hospital Systems in the Silver Spring area, who is searching for a Utilization Review Nurse/Case Manager for their Payor Reimbursement Analyst position. In this role you will support the financial sustainability of the organization through timely , accurate and thorough research of reimbursement issues related to Medicaid and Commercial payors.

Functional Responsibilities

Authorizations & Denials

Conduct timely, comprehensive, and accurate reviews of authorizations and denials to determine appropriate actions.
Provide clear guidance to resolve authorization and denial issues.
Submit timely appeals based on standardized criteria (Interqual and MCG) and adhere to escalation processes.
Monitor payer responses to appeals to ensure prompt claim payments or write-offs.
Serve as a subject matter expert for CRM, Revenue Cycle, and the organization.

Data Management

Track, trend, and analyze all authorization issues and denials by payer using relevant software.
Report data on a weekly, monthly, quarterly, or yearly basis to the Revenue Cycle team.
Propose process improvements for various stakeholders based on data analysis to prevent future denials.

Communication & Collaboration

Collaborate with internal and external partners to optimize reimbursement.
Actively participate in payer meetings to discuss authorization and denial data and trends.
Develop comprehensive appeals using standardized criteria or evidence.

Qualifications:

BSN (required), MSN (preferred)
5 years experience with at least 3 years of Utilization Review (required)
Ability to critically think and apply logic and reasoning to dynamically changing healthcare environment.
Requires superior verbal communication skills and service excellence approach with internal and external stakeholders.
Must have strong business writing skills.
Proficient at keyboarding and facile with Microsoft Office Excel, Access and Power Point.

Job Type: Full-time

Pay: $100,000.00 - $125,000.00 per year

Benefits:

401(k)
401(k) matching
Dental insurance
Health insurance
Life insurance
Paid time off
Vision insurance

Schedule:

8 hour shift
Monday to Friday

Work setting:

Hospital

Ability to Relocate:

Silver Spring, MD: Relocate before starting work (Required)

Work Location: In person

Networks Connect Professional Staffing

New Jobs

RN Case Manager/Utilization Review