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Description

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?

Summary:

+ Position Summary: The Utilization Management Specialist - Denials is responsible for evaluating medical records to determine severity of patient's illness and the appropriate patient class in accordance with industry guidelines. Serves as a liaison for patients and hospital with insurance companies.

+ Qualified individuals must have the ability with or without reasonable accommodation to perform the following duties:

+ Complete chart review and communicate patient status medical needs with insurance companies in order to advocate for patients and facilitate appropriate reimbursement.

+ Ensure that patients are assigned the appropriate patient class throughout patient stay by using Industry standard review tools, department policies, and critical thinking.

+ Occasionally coordinate with clinical staff to facilitate appropriate documentation to support patient class, optimal patient outcomes, and minimize denied days.

+ Complete all documentation, including authorizations and denials according to departmental standard operating procedures.

+ Communicate with Patient Financial Services staff regarding changes to patient class to ensure proper billing. Work with Financial Clearance and Accounts Receivable to follow up on authorization related denials.

+ Facilitate Peer to Peer appeal processes and complete written appeal processes post-denial in a timely fashion.

+ Follow up with payers to account for all bed days for authorization.

+ Maintain knowledge of specific payer requirements to ensure efficient review process.

+ Complete appropriate insurance authorization forms

+ Develop and maintain relationship with outside vendors to facilitate the appeal process

+ Manage work queue’s

+ The following duties are considered secondary to the primary duties listed above:

+ Participates in Continuous Improvement for the department and the organization.

+ Identifies professional needs to maintain expertise and keep current with health care trends, both clinical and financial

+ Participates in orientation and education of individuals to the functions of this position.

+ Other duties as assigned.

Responsibilities:

Minimum Required Qualifications:

+ Current licensure as a Registered Nurse, issued by the Pennsylvania Board of Nursing

+ Minimum of five years of nursing experience which includes a minimum of three years in an acute care hospital setting

+ Excellent written, interpersonal communication and negotiation skills. Critical thinking skills and the ability to perform clinical chart review efficiently. Strong analytical, data management and computer skills. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Ability to advocate for the patient, as well as the hospital’s best interests.

+ Ability to adjust adapt to varying needs of the department and the ever changing industry requirements

+ Ability to work independently and exercise sound judgment in interactions with the health care teamPreferred Qualifications:

+ Knowledge of health care and managed care delivery systems. This includes standards of medical practice; insurance benefit structures and related legal medical issues.

+ Knowledge of utilization management and quality improvement processes.

+ Experience working within the managed care environment.

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.

Live Your Life's Work

We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.

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