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Purpose:

Do you have experience with clinical appeals and utilization review? Are you an RN looking to grow your career? UPMC is hiring a full-time Revenue Cycle Clinical Review Nurse. This position works Monday through Friday during daylight hours. Additionally, this position is eligible to work from home.

The Revenue Cycle Clinical Review Nurse provides support to the local care management departments by initiating the retrospective appeal process for acute inpatient clinical denials and audits. The Clinical Review Nurse also serves as a clinical resource person for all Health Services Division areas. They are responsible for drawing on their clinical knowledge base and knowledge of payor regulations to assess the presence of criteria to recover denied reimbursement or support services rendered.

If this sounds like the position for you, apply today!

Responsibilities:

+ Apply understanding of utilization management as it relates to the continuum of care.

+ Assist in determining system-wide care management needs through investigation of retrospective denials or revenue cycle audits, and identification of root cause.

+ Coordinate payor audits, conduct post-audit to validate auditor findings and identify previously unbilled services.

+ Serve as a clinical liaison between revenue cycle staff, utilization review, payors and physicians when indicated.

+ Monitor and evaluate for areas of process improvement related to the retrospective appeal/3rd party audit process to ensure regulatory compliance.

+ Assist the Health Services Division in responding to billing inquiries/complaints, which require a clinical understanding.

+ Collaborate with other departments to ensure all information to support services rendered is identified.

+ Identify and assign a root cause to each case to ensure denial reasons are tracked.

+ Formulate written appeal letter or clinical summary as appropriate, incorporating supportive documentation. (i.e. medical criteria, state regulations, etc).

+ Assist in clearing claims for billing as indicated.

+ Maintain current knowledge of regulatory guidelines related to retrospective appeals and clinical reviews.

+ Maintain collaborative relationships with utilization management and appeal departments at payor organizations.

+ Negotiate agreement with payor regarding final outcome.

+ Perform clinical review for cases including, but not limited to, those referred for retrospective appeal, 3rd party audit, or validation of services rendered.

+ Complete timely and accurate appeals and/or clinical reviews using established processes.

+ Collaborate with physician leadership as warranted in preparation of appeal/clinical review responses.

+ BSN or Bachelors degree preferred.

+ Five years clinical experience required.

+ Two years payor or care management experience preferred.

+ Three to five years in a health care financial environment preferred.

+ Knowledge of medical necessity criteria (InterQual) preferred.

+ Knowledge of CPT-4 and Revenue Coding is strongly preferred.

+ Prior appeal/grievance experience preferred.

+ Knowledge of payer reimbursement structure preferred.

+ Excellent oral and written communication skills.

+ Negotiation skills

+ Critical thinking skills.

+ Organization/time management and prioritization skills.

+ Proficient in Microsoft Word and Microsoft Excel.

Licensure, Certifications, and Clearances:

+ Registered Nurse (RN)

+ Act 34

*Current licensure as a Registered Professional Nurse either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

UPMC is an Equal Opportunity Employer/Disability/Veteran