RN - Utilization Management / Clinical Denial Management

• Key Accountability: Clinical Case Review
• Demonstrates sound knowledge of Interqual criteria when conducting chart reviews.
• Utilize CERME to perform medical necessity reviews
• Conduct Admission, Observation follow up, and Continued Stay reviews, identifying cases that documentation does not support severity of illness or intensity of service, thereby failing to meet criteria for admission.
• Refer cases to Secondary Medical Review, when appropriate, for assistance in determination of proper admission status, Observation follow up, or Continued Stay status.
• Demonstrates ability to document proper order status in electronic health record.
• Demonstrate the ability to place a status order, at the direction of the provider, into the electronic health record.
• Demonstrate proficiency in the Medicaid review process, as well as the eQHealth system.
• Demonstrate knowledge of the IPO surgery list.

• Demonstrate the ability to communicate review finding with Case Management, Social Services, Providers, or other ancillary departments as part of the continuum of care for the patient.
• Provide concurrent clinical review to UR agencies and communicates discharge plan as indicated.
• Discuss concerns, comments, length of stay, or coverage concerns from UR agencies or insurance providers, with Case Management, Social Services, or providers, or other ancillary departments as appropriate.
• Provide clinical updates or requests for information to UR agencies or insurance providers in a timely manner.
• Demonstrates proper documentation of communication with UR agencies and insurance payers, physicians, Case Management, Social Services, or other Ancillary Departments, into the patient's Electronic Health Record. This pertains to communication received from such as well as communication to said parties.
• Participates in Utilization Management process for retro reviews, denials, P2P notifications to providers and follow up, and appeals.
• Utilizes E.HR as applicable to assist in denial management as requested.
• Complete follow up calls to UR agencies and insurance providers for certification of days as necessary.
• Act as a resource to ED/Surgery staff on weekends, in reviewing intensity of service, severity of illness, and documentation to support admission status when requested.
• Act as a resource, when requested, to those who may need Utilization Management support or assistance, in providing for the continuum of care for the patient.

• Creates a welcoming environment for the person's served. Effectively manages positive relationships with staff, physicians, ancillary staff, and third party payers.
• Monitors and completes accounts on multiple work queues in electronic medical record.
• Monitors requests in work queue for clinical information. Prepares/faxes documents for review, to third party payers. Ensures receipt of documents. Documents sending of clinical information in patient chart.
• Monitor/document third party payers approved days, denials, requests for further information.
• Communicate opportunities for Peer to Peer from third party payers, with our physicians (at Methodist/Proctor/Pekin). Document requests/results of Peer to Peer conversations in patients electronic health record.
• Other duties as assigned, to meet the day to day operational needs of Utilization Management.

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Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.

Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We've grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We're developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world's first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet designations, the nation's highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.