Easter Seals Jobs

Overview

This position, under Revenue Cycle Management, is responsible for the completion of admission and continued stay clinical review, including obtaining insurance certification/authorization necessary to secure reimbursement. This position assesses the patient’s plan of care and progress of the patient throughout an acute care and/or outpatient episode (observation) across the M Health Fairview system.

Responsibilities Job Description

Job Expectations:

• Perform and document timely and accurate utilization management review to ensure compliance with all policies, procedures, regulatory and accreditation requirements.

• Adhere to applicable professional standards using nationally recognized evidence-based clinical criteria and M Health Fairview guidelines to determine the appropriateness of level of care, length of stay and discharge planning.

• Facilitate secondary physician review with the physician advisor and/or attending physician on required cases to ensure accurate level of care assignment and reimbursement.

• Manage resolution of concurrent payer denials through submission and coordination of appeals related to medical necessity (level of care) and tracks all work related to denials/appeals.

• Educate internal members of the health care team on utilization management workflow and managed care concepts.

• Work on a variety of special projects and assume other duties as assigned by the Utilization Review Manager or Supervisor.

• Understand and focus on key performance indicators.

• Contribute to the process or enablement of collecting expected reimbursement.

• Understand and adhere to Revenue Cycle’s Escalation Policy.

Organization Expectations, as applicable:

• Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served.

• Partners with patient care giver in care/decision making.

• Communicates in a respective manner.

• Ensures a safe, secure environment.

• Individualizes plan of care to meet patient needs.

• Modifies clinical interventions based on population served.

• Provides patient education based on as assessment of learning needs of patient/care giver.

• Fulfills all organizational requirements.

• Completes all required learning relevant to the role.

• Complies with and maintains knowledge of all relevant laws, regulations, policies, procedures, and standards.

• Fosters a culture of improvement, efficiency, and innovative thinking.

• Performs other duties as assigned.

Qualifications

Required

Education

• Bachelor’s degree in Nursing

Experience

• 3-5 years Utilization Review or Case Management experience in hospital, clinic, insurance company, or long-term care facility.

• Minimum of 1-3 years of acute care hospital nursing experience.

License/Certification/Registration

• Current RN License

Preferred

Education

• NA

Experience

• Minimum of 1-year Epic experience.

• Minimum 1-year experience using medical necessity screening criteria, such as InterQual or MCG.

• Minimum of 3-5 years of acute care hospital nursing experience.

• Excellent computer and database management skills.

EEO Statement

EEO/AA Employer/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status

Benefit Overview

Fairview offers a generous benefit package including but not limited to medical, dental, vision plans, life insurance, short-term and long-term disability insurance, PTO and Sick and Safe Time, tuition reimbursement, retirement, early access to earned wages, and more! Please follow this link for additional information: https://www.fairview.org/careers/benefits/noncontract

Compensation Disclaimer

An individual's pay rate within the posted range may be determined by various factors, including skills, knowledge, relevant education, experience, and market conditions. Additionally, our organization prioritizes pay equity and considers internal team equity when making any offer. Hiring at the maximum of the range is not typical.