Job Opening For Case Manager Nurse (USRN) - Medical Billing

USRN Case Manager Nurse

The case manager nurse will regularly liaise with multiple clinical specialties and doctors. This role also involves consistent interactions with insurance providers, patients and their families, legal delegates, and representatives from other medical care institutions. Additionally, they will often communicate with nursing staff, billing teams, medical social workers, and personnel from various departments.

Primary Roles Responsibilities:

Performs case management, including obtaining prior authorization for drugs and procedures according to hospital policy and procedures
Promotes, coordinates, and takes responsibility for completion of all activities associated with case management
Ensure that all patient information is handled in accordance with HIPAA regulations
Ability to perform tasks in line with authorizations for outpatient services, denial letters, and similar activities

Qualifications:

Graduate of BS Nursing, USRN required
At least 2 years previous hospital nursing experience or case management experience in a clinical setting for a US-based healthcare company, required
Two years previous hospital nursing experience, preferred
Excellent verbal and written communication skills; ability to communicate with attending physicians regarding clinical determinations; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
High level of integrity as demonstrated by appropriate treatment of confidential information, adherence to policies, procedures, rules and regulations, professional conduct in dealing with persons internal and external to the organization, and sensitivity to the populations served and the providers with which MHS works
Demonstrated knowledge of payers, payer systems, cost effective utilization management, insurance terminology, InterQual criteria and Milliman guidelines, preferred
Clinical competence in understanding hospital care and care coordination
Ability to apply InterQual and other applicable criteria for all applicable inpatients and outpatients on a concurrent basis
Ability to write appeals letters and ability to follow through for successful appeals
Proficient computer and software skills

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