Outcomes Manager, Utilization Review RN, Part Time, Remote

Virtua is South Jersey’s largest health system, committed to the mission of helping people be well, get well, and stay well and averaging more than one million patient encounters each year. Virtua’s 14,000-plus employees provide comprehensive care at five hospitals and nearly 300 other locations, in addition to bringing health services directly into communities through home health, rehabilitation, mobile screenings, and its paramedic program. Virtua has more than 2,850 affiliated doctors and other clinicians, and its specialties include cardiology, orthopedics, advanced surgery, and maternity. Virtua is affiliated with Penn Medicine for cancer and neuroscience, and the Children's Hospital of Philadelphia for pediatrics. As a not-for-profit, Virtua is committed to the well-being of the community and provides innovative outreach programs that address social challenges affecting health, from addiction and other behavioral issues to lack of nutritious food and stable housing. A Magnet-recognized health system ranked by U.S. News and World Report, Virtua has received many awards for quality, safety, and its outstanding work environment. For more information, visit virtua.org. To help Virtua make a difference, visit foundation.virtua.org. Connect with Virtua on Facebook, Twitter, and Instagram at @VirtuaHealth.

Job ID: R1056390 Type: Part Time Location: Pennsauken, New Jersey Standard Hours: 20 Shift: 1st Shift Remote work environment after successful completion of in-office training Summary: Responsible for application of appropriate medical necessity tools to maintain compliance and achieve cost effective and positive patient outcomes. Acts as a resource to other team members including UR Tech and AA to support UR and revenue cycle process.

Utilization Management: Utilizes Payer specific screening tools as a resource to assist in the determination process regarding level of service and medical necessity. Consults with Physician Advisor to discuss medical necessity, length of stay, and appropriateness of care issues. Identify and manage concurrent and retroactive denials through communication with attending physicians, case management, multidisciplinary team, external physician resource group and payers. Documentation: Appropriate and complete documentation of clinical review and denial management in the case management documentation system and in the billing system. Denial Management: Manages the concurrent denial process by referring to appropriate resource for concurrent and retrospective appeal activity process. Prepares and facilitates audits using appropriate screening tools and documentation. Metrics: Accountable to job specific goals, objectives and dashboards which contribute to the success of the organization. Participates in organizational improvement activities including patient satisfaction, Six Sigma committee, department and/or divisional teams and community activities. Compliance: Understands and applies applicable federal and state requirement. Identify and reports compliance issues as appropriate.