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:
Ability to Relocate:
- Silver Spring, MD: Relocate before starting work (Required)
Work Location: In person
