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Referral Clinical Review RN

Company: UCHealth
Location: Arvada
Posted on: February 21, 2021

Job Description:

Summary:
Establishes medical necessity for advanced services and procedures. Liaisons with providers, payers, and others to facilitate navigation of complex authorization and reimbursement processes.

Work Schedule: Full Time Days

Responsibilities:
Reviews clinical documentation and guidelines for pending referrals, calling when necessary in an attempt to obtain authorization, mitigating the need for physician calls. Facilitates peer-to-peer reviews as needed.

Identifies documentation requiring clarification, communicating with providers or other healthcare professionals to ensure medical necessity is supported. Serves as a resource to providers and other healthcare professionals regarding appropriateness of clinical documentation.

Determines that medical necessity documentation and intent is established to meet Medicare compliance for diagnosis codes entered by providers. Changes diagnosis codes and documents details in EMR as needed.

Initiates complex referrals on authorization portals, and trouble-shoots how best to navigate portals to obtain authorizations upon submission.

Within scope of job, requires critical thinking skills, decisive judgement and the ability to work with minimal supervision. Must be able to work in a fast-paced environment and take appropriate action.

Requirements:

  • Credentials:
    Essential:
    * Registered Nurse
  • Other information:
    Minimum Required Education: Bachelor's degree in Nursing from an accredited Registered/Professional Nursing program.
    Required Licensure/Certification: State licensure as a Registered Nurse (RN).
    Minimum Experience: 3 years of experience as an RN.
  • IF APPLICABLE: BLS through the American Heart Association or the American Red Cross CPR for the Professional Rescuer with card in-hand before start date. BLS or CPR card must be good through sixty days of hire. All life support certification cards must be issued by either the American Heart Association or the American Red Cross CPR for the Professional Rescuer. (American Red Cross for the Professional Rescuer is only good upon hire and all renewals will need to be through an American Heart Association sanctioned course.) IF APPLICABLE: Are you a RN New Grad? Visit to find out about our exciting New Grad opportunities!



    This position's pay range starts at: $31.230000/hour.


    An annual bonus may be paid to eligible employees based upon organizational and individual performance.

    UCHealth offers their employees a competitive and comprehensive total rewards package. Some of the many benefits included in this package are full medical, dental and vision coverage; retirement plans; paid time off; employer-paid life and disability insurance with additional buy-up coverage options; tuition and continuing education reimbursement; and a full suite of voluntary benefits such as identity theft protection and pet insurance. Our employees and their family members have full access to our Employee Assistance Program, which includes up to 5 free counseling visits and work/life solutions, such as one free legal consultation. In addition, other emotional counseling support is available depending upon their need.

    At UCHealth, we do things differently

    We believe in something different: a focus on the individuality of every person. In big ways and small, we exist to improve the extraordinary lives of all those we serve. As Colorado's largest and most innovative health care system, we as a team deliver on the commitment to provide the best possible experience for our patients and their families. We foster a true human connection and give people the freedom to live extraordinary lives. A career at UCHealth is more than a job, it's a passion.

    Going beyond quality requires the perfect balance of talent, integrity, drive and intellectual curiosity. We are looking for individuals who recognize, like us, that the world of medicine is ever-changing and are motivated to do what is right, not what is easy. We support creativity and curiosity so that each of us can find the extraordinary qualities within ourselves. At UCHealth, we'll do everything in our power to make sure you grow and have a meaningful career. There's no limits to your potential here.

    Be Extraordinary. Join Us Today!

    UCHealth recognizes and appreciates the rich array of talents and perspectives that equal employment and diversity can offer our institution. As an affirmative action/equal opportunity employer, UCHealth is committed to making all employment decisions based on valid requirements. No applicant shall be discriminated against in any terms, conditions or privileges of employment or otherwise be discriminated against because of the individual's race, creed, color, religion, gender, national origin or ancestry, age, mental or physical disability, sexual orientation, gender identity, transgender status, genetic information or veteran status. UCHealth does not discriminate against any "qualified applicant with a disability" as defined under the Americans with Disabilities Act and will make reasonable accommodations, when they do not impose an undue hardship on the organization.

Keywords: UCHealth, Arvada , Referral Clinical Review RN, Healthcare , Arvada, Colorado

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