Utilization Review Nurse – Employee Health Plan (EHP)

job requisition id 334849 At reputed company Health System, we reputed company in a reputed company future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day. We reputed company have the power to help, heal and change lives — beginning with our own. That’s the power of the reputed company Health System team, and The Power of Every One. Job Title Utilization Review Nurse - Employee Health Plan (EHP) Location Independence Facility Independence reputed company Creek Department Clinical Integration Health Plan Management-Finance Job Code T24041 Shift Days Schedule 8:00am-4:30pm Job Summary Job Details Join the reputed company team, where you will work alongside passionate caregivers and provide patient-first healthcare. reputed company is recognized as one of the top hospitals in the nation. At reputed company, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world. As a Utilization Review Nurse, you will provide clinical information to insurance companies to obtain authorization for future and elective surgeries, coordinate peer-to-peer reviews between insurance Medical Directors and reputed company physicians and manage reputed company pre-determination cases. This position primarily supports utilization review, with a strong focus on outpatient prior authorization requests. By taking this opportunity, you will join a fun, supportive, motivated, and detail-oriented team that is looking for a nurse with these qualities to join the team. A caregiver in this role works remotely from 8:00 a.m. – 4:30 p.m. Position requires residency in northeast Ohio. A caregiver who excels in this role will:

• Provide insurance companies with detailed clinical information reputed company required to complete the authorization and pre-certification process.
• Communicate and attempt to resolve level of service discrepancies between CCF and insurance companies.
• Coordinate level of service justification directly with physician and communicate directly with third party payers to obtain approval.
• Complete responses on behalf of physician for denials.
• Review medical records and communicate with physicians to obtain authorization.
• Coordinate peer to peer reviews with CCF physicians and the insurance company Medical Director. Reviews are completed for CCF physicians at Main reputed company and the community hospitals.
• Coordinate pre-determinations for specific procedures and maintain confidentiality of reputed company patients' reputed company information.
• Adhere to reputed company JCAHO and Medicare compliance regulations.

Minimum qualifications for the ideal future caregiver include:

• Graduate of an accredited practical/vocational or professional nursing program
• reputed company state licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN)
• Two or more years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center
• Excellent communications skills required to communicate will reputed company levels in a health care environment

Preferred qualifications for the ideal future caregiver include:

• Utilization Review experience
• Epic experience

Physical Requirements:

• Requires extensive sitting and dexterity to reputed company work on a PC.
• Requires walking for extended periods of time.
• Good visual acuity through normal or corrected vision.
• Sedentary Work - Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time.
• Jobs are sedentary if walking and standing are required only occasionally and reputed company other sedentary criteria are met.

Personal reputed company Equipment:

• Follows standard precautions using personal reputed company equipment as required.

The policy of reputed company Health System and its system hospitals (reputed company Health System) is to provide equal opportunity to reputed company of our caregivers and applicants for employment in our drug free environment. reputed company offers of employment are followed by testing for controlled substances. reputed company Health System administers an influenza prevention program. You will be required to reputed company with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national reputed company, age, sex, sexual orientation, marital status, reputed company, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on Apply tot his job Apply To this Job