Job Description:

Uses nationally recognized, evidence-based utilization criteria to review medical records and perform clinical assessments for patient accounts to be appropriately appealed. Attends and testifies at hearings on behalf of the patient and Intermountain Healthcare when insurance companies are disputing the medical necessity of the admission. Reports to the Director of Audit and Appeals in the Revenue Integrity Department.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Uses nationally recognized evidence-based utilization review criteria to assess and write up clinical reviews for insurance audits and governmental insurance appeals using supporting documentation.

2. Assesses the appropriateness of clinical appeal requests by using payer policies and Federal and State regulations.

3. Works with Physician Advisors to obtain clinical support for appeals if needed.

4. Collaborates with Care Management, Utilization Review, Physician Advisors, Revenue Integrity, Compliance, Legal Counsel and the RCO teams to prepare appeals.

5. Identifies trends and works with the appropriate multidisciplinary teams to improve denial management, documentation and appeals processes.

6. Supports and works with legal counsel to prepare for Administrative Law Judge hearings as part of the appeal process.

EDUCATION

Required :

Graduate of an accredited school of nursing is required (Associates or Bachelor’s degree)

Preferred :

Bachelor’s degree (BSN) is preferred.

CERTIFICATION, REGISTRATION, LICENSE

(*indicates primary source verification requirement)

Required :

Current valid RN License is required

EXPERIENCE

Required :

Three (3) years experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting required.

Preferred :

Five (5) years experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting required.

Physical Requirements:

Anticipated job posting close date:

09/04/2024

Location:

Lake Park Building

Work City:

West Valley City

Work State:

Utah

Scheduled Weekly Hours:

40

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

$39.99 - $59.18

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits packages for our Idaho, Nevada, and Utah based caregivers , and for our Colorado, Montana, and Kansas based caregivers ; and our commitment to diversity, equity, and inclusion .

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.