Case Manager, Denials and Appeals, 40 Hours (Days)

Job description

The UM RN will be responsible for review of potential transfers to the BMC System for tertiary care, in conjunction with the multidisciplinary care team, utilizing medical necessity screening tools to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay. This nurse secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required and follows the UR process, in addition to the pre-denial process as defined in the attached job description and in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review. POSITION SUMMARY: Utilizing a collaborative process, the care manager will assess, plan, implement, monitor, and evaluate the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes. The care manager helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in...