Job Description

Job Title: Authorization Nurse - Inpatient Acute Care Management
Job ID: 731007
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility:
Department: Rev Cyc Care Mgmt
Location: , Pittsburgh PA

Description

Are you an experienced inpatient nurse looking for an opportunity to progress to a thriving professional environment? Do you have previous experience within inpatient acute care management and possess strong knowledge of inpatient authorizations and utilization review? Our Revenue Cycle Care Management division is looking for a energetic, motivated candidate for our regular full-time inpatient Authorization Nurse opening!

This position will work standard daylight hours, Monday through Friday, with a weekend rotation.

The rapidly growing Care Management group is a division of UPMC Corporate Services Revenue Cycle, and is primarily responsible for handling centralized utilization review and clinical appeals work across the UPMC system. Our office is located in the South Side neighborhood in the City of Pittsburgh.

As a full-time UPMC employee, you will have access to our comprehensive, inexpensive employee-cost benefits packages, including medical, dental and vision care, retirement benefits, paid holidays and paid time off, and so much more!

A key role within these operations, the fantastic role of Authorization Nurse provides support to appropriate UPMC departments and health care providers by obtaining referrals and/or authorizations for any inpatient service or treatment. In this role, you will draw on a clinical knowledge base and knowledge of payor regulations in order to assess medical necessity and ensure the presence of supporting documentation to obtain authorization.


Responsibilities:
  • 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.
  • Effectively communicates pertinent clinical information to the payor in order to obtain authorization for inpatient services.
  • 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.
  • Maintains patient certification information, enters certification data in appropriate systems and communicates certification status to floor Care Managers/insurance verification, transplant credit, etc.
  • Maintains the denial management processes for concurrent denials/appeals, tracking and reporting denial information.
  • Monitor and evaluates for area of process improvement related to the payor specific authorization process.
  • Monitors the collection, copying and transmittal of pertinent clinical information required to obtain insurance authorization.
  • Perform clinical review for cases referred for cases requiring authorization or adherence to payor medical policies.
  • Performs medical record review as needed to provide necessary clinical information to payor.
  • Provide ongoing education/feedback to care managers and other departments as related to the payor specific authorization process.
  • Provides prompt payor feedback to Care Managers/Social Workers enabling them to re-evaluate/re-direct the current patient plan of care in order to streamline the delivers of services.
  • 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.
  • Serves as a liaison between the floor Care Managers and Payors and facilitates payor/physician contact when indicated.
  • Serves as a resource on payor requirements for Severity of Illness (SI) and Intensity of Service (IS) determinations including observation and inpatient status.

Qualifications

  • BSN or Bachelors degree preferred
  • Licensed RN in the State of Pennsylvania
  • NY RN license a plus
  • 5 years clinical experience
  • 2 years payor or care management experience
  • Understanding of clinical and care management process
  • Inpatient nursing experience strongly preferred
  • Knowledge of medical necessity criteria (InterQual)
  • Ability to apply InterQual criteria appropriately
  • Prior utilization review experience
  • Knowledge of payor reimbursement structure
  • Excellent customer service skills
  • Negotiation skills for obtaining appropriate level of care
  • Critical thinking/assessment skills
  • Self motivation/autonomy
  • Organization/time management and prioritization skills
  • Proficient in Microsoft Word and Microsoft Excel
  • Experience working with databases preferred

Licensure, Certifications, and Clearances:
  • Registered Nurse

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $28.37 to $47.88

Union Position: No

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