Utilization Review Coordinator jobs in Portsmouth, NH

Hybrid opportunity, must be local to Exeter, NH. 

Exeter Hospital, Core Physicians, and Rockingham VNA & Hospice, part of Beth Israel Lahey Health, proudly serve the beautiful NH seacoast region. Our principal mission is to work together to create healthier communities. What makes us unique is the spirit of our staff who are team-oriented and focused on providing an outstanding patient care experience and quality outcomes for those we are privileged to serve. In addition, we want to ensure that our employees feel well cared for by offering a comprehensive benefits package, on-going training and growth opportunities, wellness resources, special perks, and more.

Our Magnet designation is recognition of our excellent nursing staff and the high quality, innovative patient care we deliver every day in our community.

Provides coordination of benefits and related services to specific patient groups to assure the highest quality of care is provided in a cost-effective manner. Works with insurers the PRO for Medicare and Medicaid billing physicians and a variety of other decision-makers for medical appropriateness.

Requirements:

• 1-3 years experience
• RN license - NH or other Compact State
• Utilization Management Certified within 1 year of hire

Major Responsibilities:

1. Reviews all admissions and provides clinical information to third party payors as required by contracts.
2. Maintains a working knowledge of nationally accepted criteria sets (Milliman and Interqual) for inpatient vs outpatient status.
3. Attends complex discharge rounds on Wednesday when scheduled.
4. Links Utilization Management with Case Management .
5. Reviews notices of potential denials and respond appropriately; ie facilitate Physician to Physician appeals when appropriate and assist with construction of appeal letters.
6. Tracks denial information for reporting to Quarterly UR Committee.
7. Provides ongoing education to the medical; nursing and hospital staff on current utilization practices and documentation requirements.
8. Collaborates with Pre-cert and Patient Accounts staff as needed to ensure proper payment.

Learn more about Nursing at Exeter here: Nursing at Exeter