Utilization Review Nurse RN
Prime Healthcare
Utilization Review Nurse RN
Prime Healthcare
Acquires and reorganizes underperforming hospitals
Central Maine Healthcare is an integrated healthcare delivery system serving 400,000 people living in central, western and Midcoastal Maine. CMH's hospital facilities include Central Maine Medical Center in Lewiston, Bridgton Hospital and Rumford Hospital. CMH also supports Central Maine Medical Group, a primary and specialty care practice organization. Other system services include the Central Maine Heart and Vascular Institute, a regional trauma program, LifeFlight of Maine's southern Maine base, the Central Maine Comprehensive Cancer Center and other high-quality clinical services.
Responsible for the quality and resource management of all patients that are admitted to the facility from the point of their admission and across the continuum of the health care management. Conducts medical necessity review of all admissions. Utilizes approved clinical review criteria todeterminemedical necessity foradmissionincludingappropriate patientstatus and continued stay reviews. Communicates all medical necessity review outcomes and denials to case management staff andproviders.Engage in denial management protocols including Peer to Peer with Physicians and Reconsideration reviews. Accurate andtimelyrecording of data in the Authorization tool. Prioritizes patient reviews based on situational analysis. Directs physician and patient communicationregardingnon-coverage of benefits and continued stay denials.
EDUCATION, EXPERIENCE, TRAINING
1. Two (2) years clinical experience as a Case Manager in an acute care, post-acute, or payer setting within the last 5 years.
2. Utilization review and denial management experience required.
3. Current state RN licensure required.
4. Must be able to communicate in English (Speak, Write)
5. Demonstrates: - excellent communication skills both verbal and written - ability to facilitate and collaborate with an interdisciplinary team - flexibility to manage multiple complex cases simultaneously - attention to detail and follow-up - critical thinking and problem-solving skills.
6. Current BLS (AHA) certificate
7. Case Management Certification (CCM) preferred.
8. Current knowledge Clinical Criteria including Milliman are Guild lines and InterQual Guidelines for severity of illness if service,
9. Current knowledge of CMS guidelines for clinical review and conditions of Participation.
Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf
Acquires and reorganizes underperforming hospitals
Prime Healthcare operates a network of hospitals and outpatient centers across the United States, concentrating on turning around financially struggling facilities. It invests in infrastructure and technology, restructures operations, and negotiates payer terms (including pursuing higher out-of-network reimbursements) to improve financial performance, and it manages both for-profit hospitals and not-for-profit facilities through the Prime Healthcare Foundation. The company aims to raise clinical quality and patient safety while expanding access in hundreds of communities, though it has faced legal and regulatory scrutiny over billing practices and service-line decisions. Its goal is to stabilize and improve the financial and clinical performance of underperforming hospitals so they can continue serving their communities.
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