The USPI Utilization Review/Appeals RN is responsible to facilitate effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination across United Surgical Partners International (USPI) Hospitals. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity. This position manages medical necessity process for accurate and timely payment for services which may require negotiation with a payer on a case-by-case basis. This position integrates national standards for case management scope of services including:

• Utilization Management services supporting medical necessity and denial prevention
• Coordination with payers to authorize appropriate level of care and length of stay for medically necessary services required for the patient
• Compliance with state and federal regulatory requirements, TJC accreditation standards and USPI policy
• Education provided to payers, physicians, hospital/office staff and ancillary departments related to covered services and administration of benefits
• Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review
• Preparing and documenting appeal letters based on industry accepted criteria.

EDUCATION

• Ensures and provides education to physicians and the healthcare team relevant to the:
• Effective progression of care,
• Appropriate level of care, and
• Safe and timely patient transition
• Provides healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options

REQUIREMENTS

Required: 5 years of acute hospital or behavioral health patient care experience with at least 2 years utilization review in an acute hospital, surgical hospital, or commercial/managed care payer setting. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered. Experience in writing appeals.

Preferred:

• Accredited Case Manager (ACM). Previous classroom led instruction on InterQual® products (Acute Adult, Peds, Outpatient and Procedures).
• Patient Accounting experience a plus. Managed care payor experience a plus either in Utilization Review, Case Management or Appeals.
• Interaction with facility Case Management, Physician Advisor, and Revenue Cycle Team is a requirement.
• May require travel up to 25% travel across USPI hospitals. An MVR will be run on the final candidate.