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Worker Type:

Regular

Job Highlights:

Remote (candidate must live in IL, MO, OK, or WI)*

Qualifications: 2+ years of Utilization Review experience, denials and appeals experience, and knowledge of evidence-based guidlines (MCG and InterQual)

*If living in MO, OK, or WI, candidate must have multistate licensure; if living in IL, candidate must have individual state licensures for all four states (IL, MO, WI, and OK).

Job Summary:

Reviews, assesses and completes denial management activities.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

• Screens denials for possible reconsideration, peer to peer, or formal appeal.

• Collaborates with utilization management staff regarding possible reconsideration with payor.

• Collaborates with physician (advisor, attending, consultant regarding peer to peer and appeal).

• Monitors results of denial management activities. Identifies trends and escalates to appropriate individuals.

• Active participant with other members of team regarding opportunities for improvement in standard work.

• May educate case management staff and other departments regarding payer changes and denial/appeal process.

• Works in a constant state of alertness and safe manner.

• Performs other duties as assigned.

EDUCATION

• Graduate of accredited school of nursing or education equivalency for licensing

EXPERIENCE

• Three years hospital acute care registered nurse experience, with one year experience in utilization review and/or case management

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.

• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.

• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.

• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.

• Frequent keyboard use/data entry.

• Occasional bending, stooping, kneeling, squatting, twisting and gripping.

• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.

• Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

State of Work Location: Illinois

• Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)

State of Work Location: Missouri

• Registered Nurse (RN) Issued by Compact State

• Or

• Registered Nurse (RN) - Missouri Division of Professional Registration

State of Work Location: Oklahoma

• Registered Nurse (RN) Issued by Compact State

• Or

• Registered Nurse (RN) - Oklahoma Board of Nursing (OBN)

State of Work Location: Wisconsin

• Registered Nurse (RN) Issued by Compact State

• Or

• Registered Nurse (RN) - Wisconsin Department of Safety and Professional Services

Work Shift:

Day Shift (United States of America)

Job Type:

Employee

Department:

8764070033 System Care Coordination

Scheduled Weekly Hours:

40

SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status , or any other characteristic protected by applicable law. Click here to learn more. (https://www.ssmhealth.com/privacy-notices-terms-of-use/non-discrimination?_ga=2.205881493.704955970.1667719643-240470506.1667719643)