Harrison Medical-Bremerton - Bremerton, WA

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Coordinates utilization functions and personnel to comply with hospital procedures and federal regulations. Maintains, disseminates, and acts on the federal and state regulations required for Medicare and Medicaid patients. Communicates directly with physicians, as the liaison between payors and physicians to secure payment approvals/authorizations. Partners with physicians to proactively prevent likely denial situations. Obtains and documents MD orders related to status clarification. Communicates with payors applying the standard Hospital Guidelines utilized by payors (InterQual, M&R, etc). Formulates and implements policies and procedures related to utilization management once approved by management. Recommends actions of a discretionary nature that will implement and control employer policies and procedures relating to utilization management. Directs the initiation of all Notices of Non-coverage. Accountable for the entry, tracking, and analysis of all Utilization Management Module data (an example of which is Avoidable Day). Supports Harrison Medical Center's Utilization Review Committee in its activities. Actively participates in creating a positive hospital experience for patients by assisting in managing resources effectively. Prior experience with InterQual and/or Milliman criteria desired.
Minimum licensure required: RN license in Washington State and a WA State Driver's License REQUIRED.
Minimum experience : Acute care experience and utilization/payor review experience.

Additional Information

Weekend and/or Holiday Rotation may be required.

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Harrison Medical Center - 3 years ago - save job - block