ASSISTANT NURSE MANAGER, COMPLIANCE ANALYST
Apply NowCompany: University of Washington
Location: Seattle, WA 98115
Description:
Harborview Medical Center - Utilization Management
RN3, Assistant Nurse Manager, Compliance Analyst
Responsible for assisting the Utilization Management Manager in departmental management duties, as well as being a role model for departmental excellence.
Responsibilities also include:
UM Medicare Recovery Audit Contractor (RAC)/Utilization Management Liaison: Will independently serve as the primary point of contact for the Utilization Management Department as it relates to RAC Audits, Medicare RAC Audit guidelines and trends, and RAC Audit specific DRG related information.
Utilization Management: Will conduct concurrent review of a designated group of patients through the use of approved clinical indicators and medical criteria to ensure that standards of quality and appropriateness of inpatient hospital care are continually met. This requires the reporting of clinical information to multiple payers as required to obtain financial coverage for the patient and decrease the financial risk for the hospital.
UM Inpatient Denial and Appeals Program: Will provide oversight and management of this program to include direct, and independent immediate action and communication to prevent denials and/or the coordination of efforts to reverse denials based on "Lack of Clinical Information" or "Does not Meet Medical Necessity". This may require collaboration with other departments such as Patient Financial Services, Coding, and/or Compliance. Additionally this position is responsible for crafting appeal letters, tracking and documenting the status of appeals, identifying denial trends and producing monthly appeal reports on pending and resolved denials and appeal financial recoupment data. This position will also deliver de-certification paperwork to patients as required.
UM Medicare Recovery Audit Contractor Audit Liaison
Provides independent management and oversight of the UM Medicare RAC Audit Appeals Program.
Serves as the primary department contact for Medicare RAC Audit information and/or issues.
Responsible for the timely and autonomous development and submission of all Medicare RAC Audit correspondence originating from UM.
Develops tracking and reporting tools for monthly RAC audit statistics.
Collaborates with other departments, such as Compliance, as necessary for successful RAC Audit outcomes for the UM Department.
Responsible for department procedure development related to RAC Audit protocol.
Provides feedback loop input into UM documentation procedures to help decrease any RAC Audit negative findings.
On a monthly basis, reports on RAC Audit Appeal Program financial status to Director of Care Management.
Utilization Management
Monitors length of stay by performing admit, concurrent and retrospective reviews using Interqual, or other criteria. Ensures patient is in the appropriate admission status with a documented Physician Order.
Acts as a resource on information regarding patient level of care, symptom severity, care intensity, and funding, to the inpatient multidisciplinary teams to help in decision making and efficient use of hospital resources.
Review select post discharge/pre-billed medical records using Interqual criteria to insure correct classification of patient status prior to billing; identify and refer any problems with coding or documentation that affect the status as appropriate. Participates in departmental audits and retro reviews.
Interacts with external utilization review organizations or payers as directed by Admitting/Financial Counseling for inpatient concurrent review approvals, keeps physicians informed of problems and documents authorization numbers in UM Computer Systems to facilitate billing.
Documents variance reasons as to why a patient is not meeting inpatient level of care. Monitors and amends as appropriate to insure accuracy.
Initiates and/or delivers Medicare, Medicaid, hospital initiated or private insurer denial letters per UM procedure.
Facilitates improved team documentation in medical record.
Performs daily data down load and up load, and laptop maintenance function.
Functions as a productive member of the UM team meeting UM Benchmarks for FTE worked.
Works with PFS, Coding, and Compliance to solve billing problems related to case status, denials or Variance Days.
Participates in UM Department audits and retro reviews.
Participates in Care Management Departmental management duties in the absence of departmental management staff.
UM Inpatient Denials and Appeals Program
Provides independent management and oversight of the UM Inpatient Denials/Appeals Program.
Autonomously analyzes clinical denials by insurers, looking at "Severity of Illness" and "Intensity of Service" Interqual Criteria, coding, DRG, and communications to and from insurers, to formulate basis for clinical and financial appeal if appropriate.
Coordinates efforts to reverse denials for individuals and/or trends.
Creates all Appeal correspondence and assembles necessary and appropriate documentation.
On a monthly basis, reports on Denial/Appeals Program status and potential financial recoupment to Director of Care Management.
Requirements:
1. Current license to practice as a Registered Nurse in the State of Washington (or applicable multistate RN license).
2. Minimum of three years professional nursing experience in an Acute Care setting.
3. 1-2 years of Utilization Management, Case Management and/or Medical Auditing experience.
4. Interqual Criteria experience.
5. Program Management experience.
6. Proven ability to work independently with demonstrated good judgment and problem solving skills.
7. Effective interpersonal, professional communication and computer skills.
8. Proficiency in computer applications for reporting purposes such as Excel.
9. Basic knowledge of DRG based payment.
10. BSN degree.
REQUIREMENTS:
L-RN | REGISTERED NURSE LICENSE - WA State
Committed to attracting and retaining a diverse staff, the University of Washington will honor your experiences, perspectives and unique identity. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable and welcoming.
The University of Washington is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, national origin, age, protected veteran or disabled status, or genetic information.
To request disability accommodation in the application process, contact the Disability Services Office at [redacted] or [redacted].
Applicants considered for this position will be required to disclose if they are the subject of any substantiated findings or current investigations related to sexual misconduct at their current employment and past employment. Disclosure is required under Washington state law.
RN3, Assistant Nurse Manager, Compliance Analyst
Responsible for assisting the Utilization Management Manager in departmental management duties, as well as being a role model for departmental excellence.
Responsibilities also include:
UM Medicare Recovery Audit Contractor (RAC)/Utilization Management Liaison: Will independently serve as the primary point of contact for the Utilization Management Department as it relates to RAC Audits, Medicare RAC Audit guidelines and trends, and RAC Audit specific DRG related information.
Utilization Management: Will conduct concurrent review of a designated group of patients through the use of approved clinical indicators and medical criteria to ensure that standards of quality and appropriateness of inpatient hospital care are continually met. This requires the reporting of clinical information to multiple payers as required to obtain financial coverage for the patient and decrease the financial risk for the hospital.
UM Inpatient Denial and Appeals Program: Will provide oversight and management of this program to include direct, and independent immediate action and communication to prevent denials and/or the coordination of efforts to reverse denials based on "Lack of Clinical Information" or "Does not Meet Medical Necessity". This may require collaboration with other departments such as Patient Financial Services, Coding, and/or Compliance. Additionally this position is responsible for crafting appeal letters, tracking and documenting the status of appeals, identifying denial trends and producing monthly appeal reports on pending and resolved denials and appeal financial recoupment data. This position will also deliver de-certification paperwork to patients as required.
UM Medicare Recovery Audit Contractor Audit Liaison
Provides independent management and oversight of the UM Medicare RAC Audit Appeals Program.
Serves as the primary department contact for Medicare RAC Audit information and/or issues.
Responsible for the timely and autonomous development and submission of all Medicare RAC Audit correspondence originating from UM.
Develops tracking and reporting tools for monthly RAC audit statistics.
Collaborates with other departments, such as Compliance, as necessary for successful RAC Audit outcomes for the UM Department.
Responsible for department procedure development related to RAC Audit protocol.
Provides feedback loop input into UM documentation procedures to help decrease any RAC Audit negative findings.
On a monthly basis, reports on RAC Audit Appeal Program financial status to Director of Care Management.
Utilization Management
Monitors length of stay by performing admit, concurrent and retrospective reviews using Interqual, or other criteria. Ensures patient is in the appropriate admission status with a documented Physician Order.
Acts as a resource on information regarding patient level of care, symptom severity, care intensity, and funding, to the inpatient multidisciplinary teams to help in decision making and efficient use of hospital resources.
Review select post discharge/pre-billed medical records using Interqual criteria to insure correct classification of patient status prior to billing; identify and refer any problems with coding or documentation that affect the status as appropriate. Participates in departmental audits and retro reviews.
Interacts with external utilization review organizations or payers as directed by Admitting/Financial Counseling for inpatient concurrent review approvals, keeps physicians informed of problems and documents authorization numbers in UM Computer Systems to facilitate billing.
Documents variance reasons as to why a patient is not meeting inpatient level of care. Monitors and amends as appropriate to insure accuracy.
Initiates and/or delivers Medicare, Medicaid, hospital initiated or private insurer denial letters per UM procedure.
Facilitates improved team documentation in medical record.
Performs daily data down load and up load, and laptop maintenance function.
Functions as a productive member of the UM team meeting UM Benchmarks for FTE worked.
Works with PFS, Coding, and Compliance to solve billing problems related to case status, denials or Variance Days.
Participates in UM Department audits and retro reviews.
Participates in Care Management Departmental management duties in the absence of departmental management staff.
UM Inpatient Denials and Appeals Program
Provides independent management and oversight of the UM Inpatient Denials/Appeals Program.
Autonomously analyzes clinical denials by insurers, looking at "Severity of Illness" and "Intensity of Service" Interqual Criteria, coding, DRG, and communications to and from insurers, to formulate basis for clinical and financial appeal if appropriate.
Coordinates efforts to reverse denials for individuals and/or trends.
Creates all Appeal correspondence and assembles necessary and appropriate documentation.
On a monthly basis, reports on Denial/Appeals Program status and potential financial recoupment to Director of Care Management.
Requirements:
1. Current license to practice as a Registered Nurse in the State of Washington (or applicable multistate RN license).
2. Minimum of three years professional nursing experience in an Acute Care setting.
3. 1-2 years of Utilization Management, Case Management and/or Medical Auditing experience.
4. Interqual Criteria experience.
5. Program Management experience.
6. Proven ability to work independently with demonstrated good judgment and problem solving skills.
7. Effective interpersonal, professional communication and computer skills.
8. Proficiency in computer applications for reporting purposes such as Excel.
9. Basic knowledge of DRG based payment.
10. BSN degree.
REQUIREMENTS:
L-RN | REGISTERED NURSE LICENSE - WA State
Committed to attracting and retaining a diverse staff, the University of Washington will honor your experiences, perspectives and unique identity. Together, our community strives to create and maintain working and learning environments that are inclusive, equitable and welcoming.
The University of Washington is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, national origin, age, protected veteran or disabled status, or genetic information.
To request disability accommodation in the application process, contact the Disability Services Office at [redacted] or [redacted].
Applicants considered for this position will be required to disclose if they are the subject of any substantiated findings or current investigations related to sexual misconduct at their current employment and past employment. Disclosure is required under Washington state law.