At Mercy Medical Center the Utilization Review/Appeals & Denials RN performs utilization review with payers, assists the physician with level of care determinations using screening criteria, and assists the physician, bedside Registered Nurse, ICC and Social Worker with utilization management and clinical coordination of the patient’s hospital stay. Comply with CMS rules and regulations and conditions of participation as well as commercial payer specific guidelines to prevent denials and revenue loss. Our professionalism, punctuality, attendance, teamwork, and empathy are at the core of how we represent ourselves and care for our patients, together, we positively impact the lives of all our patients and their families.
What you will do
Perform utilization review and payer notification
Establish partnerships with site BPCI RN in order to align BPCI efforts with patient satisfaction outcomes
Educate patient, families and other members of the care team about the financial out of pocket expense or financial responsibility of the patient
Identify and eliminate barriers to effective patient stay management and promote improvements in work processes within department, hospital, and community
Refer quality issues and poor utilization of services to the appropriate sources
Educate hospital leadership and staff to current practices, patient coordination issues, and unit specific trends
Provide consultation to professional staff and physicians on level of care determinations, CMS regulations and payer specific guidelines
Document clinical reviews in accordance with documentation standards, policies, procedures and/or guidelines
Minimum Qualifications
Education: Graduate of an accredited college or university affiliated nursing program. BSN graduate preferred, Master's preferred
Licensure: Current Licensure as a Registered Nurse RN in Massachusetts.
Certification: BLS (AHA/ARC). CCM or ACM Certification preferred.
Preferred Skills:
3-5 years in similar experience preferred, hospital or community based. knowledge of budget processes, quality improvement, report distribution, TJC standards, state and federal regulations, six sigma and LEAN methodologies
Work Schedule:
PER DIEM as needed
Ministry/Facility Information
Mercy Medical Center has established itself as one of the leading providers of health care services in Western Massachusetts. Mercy Medical Center is a 182-bed acute care hospital in Springfield. Other facilities include Mercy's Rehabilitation Hospital, a comprehensive hospital-based rehabilitation center on the campus of Mercy Medical Center and Brightside for Families and Children, an outpatient service offering counseling and family support programs.
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.