Outcomes Manager
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Job Description
Outcomes Manager applying medical necessity criteria and managing denials for Virtua Health, a South Jersey healthcare system. Supporting utilization review, compliance, documentation and patient outcomes.
Responsibilities:
- Apply appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes
- Act as a resource to UR Tech and AA team members to support UR and revenue cycle processes
- Utilize payer-specific screening tools to assist in determining level of service and medical necessity
- Consult with Physician Advisor regarding medical necessity, length of stay and appropriateness of care
- Identify and manage concurrent and retroactive denials through communication with physicians, case management, multidisciplinary teams, external physician resource groups and payers
- Complete clinical review and denial management documentation in case management and billing systems
- Manage concurrent denial processes and refer to appropriate resources for concurrent and retrospective appeals
- Prepare and facilitate audits using appropriate screening tools and documentation
- Meet job-specific goals, objectives and dashboard metrics
- Participate in organizational improvement activities, committees, departmental/divisional teams and community activities
- Understand and apply applicable federal and state requirements
- Identify and report compliance issues as appropriate
Requirements:
- RN required
- 3 years clinical nursing (RN) experience
- 1 year UR/CM/QM experience preferred
- Basic understanding of Medicare, Medicaid and managed care
- Discharge planning or home health background
- Excellent verbal and written communication skills
- Problem solving, critical thinking and conflict resolution skills
- Graduate of an accredited School of Nursing
- Licensure from the State of New Jersey as a Registered Nurse
- Case Management Certification required within one year of hire beginning April 1, 2015
Benefits:
- Medical/prescription insurance
- Dental insurance
- Vision insurance
- Health and dependent care flexible spending accounts
- 403(b) (401(k) subject to collective bargaining agreement)
- Paid time off
- Paid sick leave as provided under state and local paid sick leave laws
- Short-term disability
- Optional long-term disability
- Colleague and dependent life insurance
- Supplemental life and AD&D insurance
- Tuition assistance
- Employee assistance program including free counseling sessions
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