Job description

Networks Connect Professional Staffing is conducting a search on behalf of our client, one of the fastest growing Hospital Systems in the Silver Spring area, who is searching for a Utilization Review Nurse/Case Manager for their Payor Reimbursement Analyst position. In this role you will support the financial sustainability of the organization through timely , accurate and thorough research of reimbursement issues related to Medicaid and Commercial payors.

Functional Responsibilities

Authorizations & Denials

• Conduct timely, comprehensive, and accurate reviews of authorizations and denials to determine appropriate actions.
• Provide clear guidance to resolve authorization and denial issues.
• Submit timely appeals based on standardized criteria (Interqual and MCG) and adhere to escalation processes.
• Monitor payer responses to appeals to ensure prompt claim payments or write-offs.
• Serve as a subject matter expert for CRM, Revenue Cycle, and the organization.

Data Management

• Track, trend, and analyze all authorization issues and denials by payer using relevant software.
• Report data on a weekly, monthly, quarterly, or yearly basis to the Revenue Cycle team.
• Propose process improvements for various stakeholders based on data analysis to prevent future denials.

Communication & Collaboration

• Collaborate with internal and external partners to optimize reimbursement.
• Actively participate in payer meetings to discuss authorization and denial data and trends.
• Develop comprehensive appeals using standardized criteria or evidence.

Qualifications:

• BSN (required), MSN (preferred)
• 5 years experience with at least 3 years of Utilization Review (required)
• Ability to critically think and apply logic and reasoning to dynamically changing healthcare environment.
• Requires superior verbal communication skills and service excellence approach with internal and external stakeholders.
• Must have strong business writing skills.
• Proficient at keyboarding and facile with Microsoft Office Excel, Access and Power Point.

Job Type: Full-time

Pay: $100,000.00 - $125,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Work setting:

• Hospital

Ability to Relocate:

• Silver Spring, MD: Relocate before starting work (Required)

Work Location: In person