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Remote Utilization Review Nurse
|Company:||Convergent||Location:||Boca Raton, Florida, United States|
|Posted:||Thursday, January 18, 2018|
Convergent employs a dedicated team of expert Healthcare Attorneys, and Account Specialists and Clinicians who navigate the entanglements of the legal system to increase reimbursement rates for our client hospitals all over the country. We apply our advanced technology to calculate anticipated payment for claims in states with complex fee schedules, allowing us to accurately identify and appeal underpaid or denied claims. Our main goal is to assist hospital systems to strengthen their financial and clinical performance. We are also a leading provider of denial management, Workers' Compensation claims resolution, and appeals solutions.
Convergent’s Boca Raton FL Insurance Department has openings for a remote Utilization Review Nurse. This is an ideal opportunity for a healthcare professional looking for remote work as the successful candidate can work anywhere in the country and report to our Boca Raton, FL office.
- Works with company’s Attorneys and Claims Representatives/Account Specialists to overturn claims denied by Commercial insurers, Medicare, Medicaid, and other third-party payers based upon medical necessity and other clinical reasons.
- Reviews physician documentation and other medical documentation for appropriateness of hospitalization in order to support medical necessity and level of care appeals.
- Prepare and submit appeals to third party payers in some cases
- Remain current on applicable UR trends and regulations
- Provide ongoing training and feedback to company’s non-clinical staff members
- Perform other related duties as required
- Licensed RN –license must be active, and in good standing.
- Two to five years of Utilization Review experience in Managed Care or Hospital Case Management, Quality Assurance, Discharge Planning or other cost management programs preferred.
- Experience/Knowledge in all clinical areas, such as Cardiology, Pediatrics, Medical Surgical, Trauma and E.R., Cancer, Behavioral Health
- Experience using InterQual criteria or Milliman criteria required.
- Experience reviewing clinical polices and guidelines, i.e. NCD/LCD coverage documents, carrier specific policies related to investigational or experimental procedures.
- Experience in an acute care hospital required. (this can be hospital-based case management either from onsite at a hospital, or on the insurance side doing hospital reviews)
- Strong problem solving and decision making skills essential.
- Strong typing and computer skills essential.
- Excellent verbal and written communication skills; ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
- Team Player - works well as a member of a group
Click Here to Apply Now