RN Utilization Review- AHN

Company :

Allegheny Health Network

Job Description :

GENERAL OVERVIEW:

Responsible for obtaining insurance precertification/recertification, functioning as a liaison with third party payers, communicating clinical information to the insurance companies as requested, addressing and resolving any actual or potential denials, and functioning as a member of the care coordination team.

ESSENTIAL RESPONSIBILITIES:

• Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party payer guidelines. (30%)

• Obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements. (30%)

• Documents, monitors, intervenes/resolves, and reports clinical denials/appeals and retrospective payer audit denials; collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor, and third party payers, etc. (30%)

• Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental/commercial payer guidelines.(5%)

• Adheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodies.(5%)

• Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.

• Assumes responsibility for AHN required continued education and own professional growth.

• Performs other duties as assigned or required.

QUALIFICATIONS:

Minimum

• Bachelor’s degree or relevant experience and/or education as determined by the company in lieu of bachelor's degree

• Current State of PA RN licensure OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC)

• Nationally recognized Care Management Certification within 5 years of start date (3 years for currently employed UR's)

• 2-3 years nursing experience with 1 year in Utilization Management

Preferred

• Experience in case management, discharge planning and/or the application of InterQual criteria

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

$31.02

Pay Range Maximum:

$48.54

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

California Consumer Privacy Act Employees, Contractors, and Applicants Notice (https://dokumfe7mps0i.cloudfront.net/oms/4391/document/2026/1/doclib\_458575\_QLVK9\_1769448333304228022\_1769448333396/1769448333396.pdf)

Req ID: J288125