Utilization Management Readmission Review Nurse
Job Location: US-Remote
Job ID: 2019-7881
Category: Utilization Management
Business Line: CMC Corporate
Who we are:
Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.
We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide.
Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.
A Day in the Life of a Utilization Management Readmission Review Nurse:
This position completes targeted reviews for authorizations that have been identified as a potentially preventable readmission. Nurse reviewers will function collaboratively with members of the Utilization Management team, Medical Directors, Claims and the Data Analytics team.
- Oversight of readmission review among the Utilization Management department.
- In conjunction with medical leadership, act as resource for criteria and readmission determination including the correct and consistent application of the InterQual criteria or policy determination
- Collaborate with various departments to ensure correct payment is processed pertaining to readmissions.
- Review clinical documentation for appropriate DRG coding against established protocols/guidelines and within established timeframes for determination of payment processing
- Contact hospital reviewers where additional information is necessary to make a decision
- Consult with Medical Director as appropriate to assist in medical necessity payment determinations
- Provide supporting documentation for denial and modification of payment decisions
What you can bring to Meridian:
- Current license (without restriction) to practice as a Licensed Practical Nurse or Registered Nurse in the designated State is required
- Three years of acute patient care with clinical background is required
- Knowledge of medical terminology, authorization processes, Medicaid, and Managed Care
- Proficient in InterQual
- Excellent computer skills
- Working knowledge of data extraction within clinical records
- Excellent communication skills
What Meridian can offer you:
- Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members.
- Opportunity to work with the industry’s leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.
- Meridian offers 401k matching that is above the national average.
- Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor’s or Master’s degrees.
- Meridian was named Detroit’s #1 Fastest Growing Company by Crain’s Magazine, so it is a great time to get involved with Meridian.
Equal Opportunity Employer