Outcomes Manager – UR
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Job Description
Outcomes Manager overseeing application of medical necessity tools for compliance. Engaging with team members and managing concurrent and retroactive denials for patient outcomes.
Responsibilities:
- Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes
- Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process
- Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity
- Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues
- Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers
- Appropriate and complete documentation of clinical review and denial management in the case management documentation system and in the billing system
- Manages the concurrent denial process by referring to appropriate resource for concurrent and retrospective appeal activity process
- Prepares and facilitates audits using appropriate screening tools and documentation
- Accountable to job specific goals, objectives and dashboards which contribute to the success of the organization
- Participates in organizational improvement activities including patient satisfaction, Six Sigma committee, department and/or divisional teams and community activities
- Understands and applies applicable federal and state requirement
- Identify and reports compliance issues as appropriate
Requirements:
- 3 years clinical nursing (RN) experience and 1 year UR/CM/QM experience or 3 years experience as Clinical Social Worker
- Basic understanding of Medicare, Medicaid and managed care
- Discharge planning or home health background
- Excellent verbal and written communication skills
- Problem solving skills
- Critical thinking skills
- Conflict resolution skills
- Licensure from the State of New Jersey as a Registered Nurse
- Case Management Certification (requirement 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) retirement plan (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 that includes free counseling sessions
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