Long Tail Health Solutions

Role Description Contractor position for ad hoc needs (PRN/0.0 hours) based on current demands of operational work. Role is designed to help fill gaps within service department and assignment could be variable day to day. - Contracted employees are expected to work with minimal oversight and modified training on assignments matched to their distinct background and experience. - Advanced or extended training may be approved based on needs of department. - Volume and schedule of hours are pre-arranged with manager in advance and approved based on contractor's availabilities and needs of the department. - The operations team works 24/7/365 mainly supporting healthcare systems with hospital sites, offering extreme flexibility in hours. - Consideration for contractors interested in working partial shifts, off-normal business hours, intermittent and variable commitment of hours, up to full-time traditional M-F allotment of work dependent on business needs of our client(s). The Utilization Management Review Nurse (UM RN) will play a crucial role in supporting our clients in the healthcare industry by providing expert clinical guidance, facilitating effective utilization management, and ensuring revenue cycle efficiency. - UM RN's oversee patient insurance authorization, compliance with governmental regulations related to hospital stays, prevention of and management of denials. - Conduct perspective, concurrent, and retrospective reviews for authorization of all Levels of Care (LOCs) and services. - Engage with program managers, reviewing records to prove and support medical necessity. - Liaise with individuals within healthcare system and hospital institutions. - Complete clinical criteria reviews related to determining appropriate LOC for hospitalized patients and aligning necessary orders and patient status. Qualifications - Registered Nurse (RN) or Licensed Practical Nurse (LPN) licensure. - Proficient or above with either Milliman (MCG) or Interqual (IQ) criteria set reviews. - Proficient in all hospital LOC: Inpatient (IP), Observation (OBS), Outpatient in a Bed (OPIB), Not Medically Necessary. - Proficient in Avoidable Day/Delay (AD) determination and documentation. - Proficient in processes for hospital medical necessity LOC and LOC status changes. - Minimum 3 years' experience in hospital level utilization management. - Minimum of 3 years of clinical nursing experience. - Strong understanding of revenue cycle management and healthcare reimbursement. - Excellent communication, interpersonal, and teamwork skills. - Ability to work independently and make sound clinical and financial decisions. - Strong analytical and problem-solving skills. - Proficient in using healthcare information systems and technology. - Commitment to maintaining patient confidentiality and ethical standards. Requirements - Bachelor of Science in Nursing (BSN) preferred. - CCM or ACM certification. - Epic EMR experience. - Account platform experience (billing and denials). - Work queue experience. Primary Job Duties - Follow Standard Operating Procedure (SOP) for all activities assigned. - Manage case/account reviews via client's EMR. - Complete work within a team approach by finalizing and organizing tasks clearly and accurately. - Use escalation pathways to resolve identified issues. - Document all activities and interactions clearly in the electronic utilization review record. - Enhance customer satisfaction among patients, families, physicians, internal and external partners, payors, and vendors. - Evaluate patient records to assess severity of illness and intensity of service. - Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays. - Conduct initial admission, continuing stay, observation and outpatient in a bed (OPIB) reviews for all patients. - Collaborate with payor sources to communicate clinical information and secure approvals. - Consult with physicians, nursing staff, and other clinical care team members. - Effectively communicate need for change in status recommendations and follow up on order entry. - Adhere to policies, procedures, regulations, and standards governing the agency. - Maintain strict confidentiality according to Federal and State guidelines. - Uphold the Professional Code of Ethics. - Other duties as assigned. Work Context - A 100% remote work force requiring strong communication and remote relationship building skills. - Contract workers are provided Azure Virtual Desktop (AVD) which includes any applications or software required for specific assignment. - Contract workers are not provided hardware (i.e. computer) and are expected to utilize virtual desktop through their self-owned hardware.