Southern New Hampshire Medical Center
Department: Patient & Family Services
Schedule: PER DIEM
The Utilization Review/Denial Specialist works with the care team to evaluate medical acuity for appropriate level of care orders and documentation to facilitate insurance coverage, and proactively prevent denials. He/She ensures level of care charges are applied accurately and meet compliance within CMS and commercial insurance guidelines. He/She reviews appeal options for medical necessity insurance denials.
- Associate Degree Science (ADN), BSN required within ten-years of hire.
- Current NH Nursing License as a Registered Nurse.
- A minimum of 5-years' of experience as a Registered Nurse.
- Experience in use of Interqual, Milliman or other Healthcare acute criteria preferred.
- Excellent written and verbal communication skills.
- Competent in Microsoft Office and general computer skills.
- Ability to achieve the following competencies within 90 days:
- Assess acute medical necessity utilizing appropriate criteria.
- Conduct charge reviews and charge entry.
- Collect and trend Utilization Review data metrics.
- Review appeal options for commercial insurance, RAC, and QIO medical necessity denials.
- Meet deadlines for the Appeal process.
- Apply CMS Regulations to meet compliance.
About Southern New Hampshire Health:
For more than 100 years, Southern New Hampshire Medical Center has honored our mission: to improve, maintain, and preserve the overall health and well-being of individuals living in the greater Nashua area by providing information, education, and access to exceptional health and medical care services.
We have literally been at the heart of better health for Greater Nashua. Our main downtown campus, a familiar landmark for generations, has grown along with the Gate City. Today, The Medical Center and our affiliated doctors and services extend across much of southern New Hampshire. Along with our growth has been the opportunity for many to build and enhance their careers within our organization. We encourage the professional and personal development of our employees and are proud of the workplace culture we have developed.
At Southern New Hampshire Health, we believe in the little moments and the power of small gestures. It is our desire to make every patient, family or visitor interaction meaningful.
You'll see some of these wonderful moments in our new video “We believe in the little moments…”
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, disability status, veteran status, or any other characteristic protected by law.