Utilization Review Team Lead | 40 Hours per Week | Utilization Review

Associate’s Degree (AA) Nursing Required

• 4-6 years Require 4-6 years clinical experience Required
• 1-3 years Previous experience in Utilization Review Required
• Registered Nurse Iowa Board of Nursing (IBON) (United States of America) Required
• Bachelor’s Degree in Arts/Sciences (BA/BS) Nursing Preferred

• →Review inpatient encounters for medical necessity-Accurate and timely record review.-Gather and analyze clinical documentation to formulate an outcome.-Making decisions based on facts and evidence; assuming responsibility for those decisions.-Monitor cases for medical necessity/level of care.-Accurate input of data.-Manage multiple priorities.-Remains current with medical and surgical procedures, products and general trends in health care delivery.-Adhere to all state and Federal regulations for all UM reviews.-Practice utilization management activities within the scope of practice.
• →Excellent Communication Skills-Effective and appropriate communication with physicians and insurance providers for the medical necessity of healthcare services.-Work incoming calls from patients, insurances, providers and facilities promptly.-Cooperate and work effectively with all department and staff to facilitate services to members and providers of care.-Maintain continuous, effective communication with other departments/disciplines.-Effective communication with patients and families regarding level of care and CMS guidelines
• →Respond to and assist the revenue cycle in claim correction. Submit appeals of denied claims. Follow up on appeals until there is resolution
• →Lead the Utilization Review team in their daily tasks and daily huddles