Senior Utilization Review Nurse

FIND YOUR FUTURE We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and a culture that fosters growth, innovation and collaboration. Overview The Contractual Reviewer-Senior will be responsible for providing an organized, timely and consistent review and investigation of provider and/or member complaints and/or appeals. The Contractual Reviewer-Senior will be required to rely on their ability to synthesize a great deal of information in the interest of effectively understanding the matter at hand to, in turn, determine the steps that need to be taken to resolve the issue. The individual will frequently be called upon to collaborate with multiple departments and associates to properly investigate appeals/complaints. The Contractual Reviewer-Senior will also be responsible for providing member education/outreach related to coverage determinations and member benefit contract information. Qualifications High school diploma or GED required. Associates degree preferred. Three (3) years of experience in a member or provider focused position required. Experience with healthcare benefits, contracts, and medical terminology preferred. Ability to understand and articulate complex issues, systems, process and/or concepts with minimal assistance from management required. Ability to analyze problems systematically, organize information, identify underlying causes and generate solutions while recognizing the impact on stakeholders and the organization. Excellent verbal, written and interpersonal communication skills required. Ability to handle escalated calls and to deliver messages clearly and articulately regarding decisions. Possess initiative, attention to detail, and solid, logical thinking capabilities. Proven ability to manage multiple, time-sensitive priorities and adherence to all deadlines, while remaining organized in a fast paced, ever-changing environment. Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable. Essential Accountabilities Research Investigate and research all levels of complaints/appeals independently to determine the resolution of the complaint/appeal. Frequent review of Independent Health policies, contracts, clinical documentation, claims systems, pharmacy formularies, procedures and department directives is required. Collaboration with internal and external resources to resolve all levels of complaints/appeals. Manage an individual workload assigned in respect to upcoming absences to adhere to regulatory timeframes. Research, investigate, and make decisions based offresearch with respect to appeals and complaints in accordance with established guidelines, regulations, and member contracts. Compliance Solid understanding of the multiple requirements that require absolute compliance in terms of the timeframes for each activity in the handling of appeals/complaints. Ensure verbal and written responses to complaints/grievances, appeals and investigations follow regulatory standards. Provide member education/outreach related to coverage determinations and member benefit contract. Identify appeal trends and process improvements where applicable. Reporting/Accuracy in Documentation Document all appeal/complaint activity thoroughly and accurately by creating a detailed summary of all findings. Information gathered in appeal/complaint activity is relied upon for internal and external reporting, so careful attention to detail is a high priority. Monitor daily reports to ensure accuracy and timeliness of complaints/grievances and appeals. Assist in continuously developing systems, workflows, and coverage criteria to better meet the needs of the customer. Coordination Coordinate and collaborate with ancillary departments and peers within the contractual team in rendering consistent coverage determinations and claims payments in accordance with policy, regulations, and member benefit contract. Demonstrate positive interrelationships and service excellence in performance of duties by meeting or exceeding the expectations of internal and external service groups. Coordinate with external agencies to prepare case files when needed for external appeals. Departmental Support Assist in meeting department goals and objectives and identify process improvements to continuously improve member/provider satisfaction. Attend assigned meetings as department representative and report to team members when necessary. Immigration or work visa sponsorship will not be provided for this position Hiring Compensation Range: $22.50 - $27.50 hourly Compensation may vary based on factors including but not limited to skills, education, location and experience. In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future. As an Equal Opportunity / Aff…? #J-18808-Ljbffr