MedPark Hospital is looking for strong Utilization Review Nurses of various levels of experience to join the Utilization Review Team and help us improve our insurance process. The Utilization Review Nurse is responsible for conducting concurrent reviews of inpatient medical records to ensure appropriate utilization of hospital resources and compliance with insurance company requirements. This role involves close collaboration with physicians, nurses, and other healthcare professionals to optimize patient care while maximizing reimbursement. The successful candidate will possess strong clinical knowledge, excellent communication skills, and a thorough understanding of insurance billing and coding practices. This is a very important role at a very important stage of our hospital. We are looking for self-motivating people with operational excellence dream and resilience to come build this dream team together.
Responsibilities:
- Concurrent Review: Conduct concurrent reviews of inpatient medical records to assess the necessity and appropriateness of services provided, ensuring alignment with insurance company guidelines.
- Insurance Communication: Act as a liaison between the hospital and insurance companies, providing clinical information and justifications for services rendered.
- Claim Management: Determine claimable and non-claimable items and procedures based on insurance policies and medical necessity. Determine the appropriate ICD codes.
- Documentation Review: Ensure accurate and complete documentation of patient care, including medical records, treatment plans, and discharge summaries, to support insurance claims.
- Pre-authorization and Certification: Obtain pre-authorizations and certifications for procedures and services as required by insurance companies.
- Appeals and Denials: Prepare and submit appeals for denied claims, providing supporting documentation and clinical rationale.
- Compliance: Maintain up-to-date knowledge of insurance policies, regulations, and coding guidelines.
- Collaboration: Collaborate with physicians, nurses, and other healthcare professionals to ensure efficient and effective utilization of resources and timely claim submission.
- Data Analysis: Analyze utilization data to identify trends and areas for improvement in resource management and claim accuracy.
- Document Preparation: Ensure all documents are appropriately filled and prepared for insurance submission, including but not limited to, medical reports, lab results, and imaging studies.
- Training: Provide training and education to hospital staff on insurance requirements and documentation standards.