COVID-19 Vaccination Information

Across UPMC, our guiding principle is to always prioritize the safety of our employees, patients, and members. UPMC believes that vaccination is important, helps protect all, and advocates that everyone who can be vaccinated should be vaccinated.

UPMC complies with all governmental requirements related to local, state, and federal COVID-19 vaccination for employment. The Jan. 13 Supreme Court of the United States decision that the Centers for Medicare & Medicaid Services federal COVID-19 vaccine mandate will move forward requires UPMC to ensure employees either get vaccinated or receive a requested medical or religious exemption.

If you are not yet vaccinated, we urge you to get a vaccine now. You can schedule your COVID-19 vaccination through UPMC or visit a non-UPMC provider or UPMC Urgent Care location.

Proof of vaccination is not required upon hire; however, employees will be responsible for ensuring post-hire compliance by getting vaccinated or requesting a medical or religious exemption.

For more information about UPMC’s response to COVID-19, please visit UPMC.com/coronavirus.

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Revenue Cycle Clinical Review Nurse

  • Job ID: 229402099
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: Corporate Revenue Cycle
  • Department: Rev Cyc Care Mgmt
  • Location: 2 Hot Metal Street, Pittsburgh PA 15203
  • Union Position: No
  • Salary Range: $31.08 to $52.46 / hour

Description

UPMC Corporate Revenue Cycle is hiring a Clinical Review Nurse to join our team!  This position will work Monday through Friday during daylight hours.  The position can start between 7:00 AM and 8:30 AM. 

The Revenue Cycle Clinical Review Nurse provides support to the local care management departments by initiating the retrospective appeal process for acute inpatient clinical denials and audits. In addition, the nurse will serve as a clinical resource person for all Health Services Division areas. Drawing on a clinical knowledge base and knowledge of payor regulations, the Revenue Cycle Clinical Review Nurse is responsible for assessing the presence of criteria to recover denied reimbursement or support services rendered.

Responsibilities:

 

  • Apply understanding of utilization management as it relates to the continuum of care.
  • Assist in determining system-wide care management needs through investigation of retrospective denials or revenue cycle audits, and identification of root cause.
  • Coordinate payor audits, conduct post-audit to validate auditor findings and identify previously unbilled services.
  • Serve as a clinical liaison between revenue cycle staff, utilization review, payors and physicians when indicated.
  • Monitor and evaluate for areas of process improvement related to the retrospective appeal/3rd party audit process to ensure regulatory compliance.
  • Assist the Health Services Division in responding to billing inquiries/complaints, which require a clinical understanding.
  • Collaborate with other departments to ensure all information to support services rendered is identified.
  • Identify and assign a root cause to each case to ensure denial reasons are tracked.
  • Formulate written appeal letter or clinical summary as appropriate, incorporating supportive documentation. (i.e. medical criteria, state regulations, etc).
  • Assist in clearing claims for billing as indicated.
  • Maintain current knowledge of regulatory guidelines related to retrospective appeals and clinical reviews.
  • Maintain collaborative relationships with utilization management and appeal departments at payor organizations.
  • Negotiate agreement with payor regarding final outcome.
  • Perform clinical review for cases including but not limited to those referred for retrospective appeal, 3rd party audit, or validation of services rendered.
  • Complete timely and accurate appeals and/or clinical reviews using established processes.
  • Collaborate with physician leadership as warranted in preparation of appeal/clinical review responses.

 

Qualifications

  • BSN or Bachelors degree preferred.
  • Five years clinical experience required.
  • Two years payor or care management experience preferred.
  • Three to five years in a health care financial environment preferred.
  • Knowledge of medical necessity criteria (InterQual) preferred.Knowledge of CPT-4 and Revenue Coding is strongly preferred.
  • Prior appeal/grievance experience preferred.
  • Knowledge of payer reimbursement structure preferred.
  • Excellent oral and written communication skills.
  • Negotiation skills.
  • Critical thinking skills.
  • Organization/time management and prioritization skills.
  • Proficient in Microsoft Word and Microsoft Excel.


Licensure, Certifications, and Clearances:

  • Current licensure as a Registered Professional Nurse either in the state where the facility is located or in a state covered by a licensure compact agreement with the state where the facility is located.
  • Registered Nurse (RN)

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct