RN
Ref No.: 16-00654
Location: Pittsburgh, Pennsylvania
Position Type:Right to Hire
Start Date: 03/08/2016
 Case Manager RN needed in Pittsburgh, PA area.

Job Description or Additional Skills: Authorization Nurse •Act as a resource to other departments as well as the care managers leveraging clinical expertise relative to the authorization process.
•Assist in determining system-wide care management needs through investigation of authorization process and identification of root cause.
•Collaborate with other departments to ensure all information/documentation is obtained to support authorization, level of care and/or medical appropriateness.
•Communicates to the Medical Directors, Attending Physicians and/or CFO, if indicated, regarding evaluation of medical appropriateness.
•Ensure clinical review process is followed in order to meet payor deadlines.
•Identify and assigns a root cause to each case to ensure denial reasons are tracked.
•Maintain collaborative relationships with utilization management and departments at payor organizations.
•Maintain current knowledge of regulatory guidelines related to authorizations.
•Monitor and evaluates for area of process improvement related to the payor specific authorization process.
•Perform clinical review for cases referred for cases requiring authorization or adherence to payor medical policies.
•Provide ongoing education/feedback to care managers and other departments as related to the payor specific authorization process.
•Report to management on an ongoing basis trends/barriers that could necessitate process improvement from a concurrent standpoint.
•Serve as a liaison between care managers and payors and facilitates payor/physician contact when indicated.

Retrospective Appeals Nurse
•Act as liaison to other departments as well as the care managers relative to the retrospective appeal process.
•Assist in determining system-wide care management needs through investigation of retrospective denials and identification of root cause.
•Collaborate with other departments to ensure all information to support retrospective appeal is identified.
•Communicate to the Care Management Director, CEO, and CFO on a regular basis the top ten account report related to their facility.
•Ensure the appeal process is followed in order to accomplish timely and appropriate appeals.
•Formulate written appeal letter as appropriate incorporating supportive documentation. (i.e. medical criteria, state regulations, etc).
•Identify and assign a root cause to each case to ensure denial reasons are tracked.
•Maintain collaborative relationships with utilization management and appeal departments at payor organizations.
•Maintain current knowledge of regulatory guidelines related to retrospective appeals.
•Monitor and evaluate for areas of process improvement related to the retrospective appeal process.
•Perform clinical review for cases referred for retrospective appeal to determine if appeal is warranted.
•Provide ongoing education to care managers and other departments related to the appeal process.
•Serve as a liaison between care managers and payors and facilitates payor/physician contact when indicated.


Dates: 3/8/2016 - 5/2/2016

Shift Days: Monday, Tuesday, Wednesday, Thursday, and Friday
Shift Start/End Times: 08:00 AM - 04:30 AM

 

Please call Gina at 814-935-7084 to discuss the opportunities! Alternatively you can email your resume to me at gina.mcgrath@aequorhc.com.
 
This is a great opportunity and this position will be filled quickly, please respond asap!
 
Perm, Travel, Contract and Per Diem shifts also Available Nationwide.
 
"We like referrals and will pay you for them too”
 
Benefits:
Excellent Compensation package!
Weekly pay with direct deposit!
Tax Advantage program.
Completion Bonuses
401K Medical Dental and Vision
Travel Reimbursement
 
About Aequor Healthcare Services:
Aequor Healthcare Services is one of the premier staffing solutions firms in the nation.  Since 1989 we have paved a way for Technical, Allied and Nursing Professionals to grow and have been able to offer some of the best positions and benefit packages in the industry.  We are committed to personnel service above and beyond, for our clients and professionals alike.  We currently have thousands of open positions Nationwide.  If we don't have the location or setting in our current database that fits your needs.  Aequor is committed to finding your specific interest and will direct market you to our healthcare client partners to find the opening that is right for you.  That's just one way we are here to give you the personal attention you deserve!