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Corporate Director of Utilization Review in Hollywood, FL at Avante

Date Posted: 1/24/2019

Job Snapshot

Job Description

Are you an experienced MDS Nurse looking to enter the Corporate arena?  

Are you seeking a company offering growth, stability, and a family-like atmosphere?

 

Avante is seeking a Corporate Director of Utilization Review to conduct and coordinate review of Medicare, Insurance, Managed Care claims and processes, and requests for Medical Records. Will ensure timely follow up of review of records for accuracy and completeness.  Maintain current knowledge of claims processing and medical reviews by fiscal intermediaries and the Medicare Integrity Program.  Work with Corporate and Regional team as needed to facilitate approval of claims, reviews and the appeal process. Provides oversight over clinical reimbursement and efforts to improve Quality Measures throughout the organization.  Provides oversight to the accuracy of assessments and accuracy of care plans through Quality Improvement Initiatives.

 

Essential Job Functions: Responsibilities include but are not limited to the following:

  • Obtains from facilities and provides timely review of Medicare, Insurance, Managed Care and related records prior to submitting them to the fiscal intermediary (FI).  Ensures records are accurate, complete, so as to enable the FI to perform a valid review.
  • Makes independent decisions, as necessary, based on the facts and circumstances of the claims in question. 
  • Ensures a timely follow up review of records when appeals, hearings, and other post-denial actions are warranted.
  • Attends Administrative Law Judge (ALJ) hearings as needed.
  • Ensures compliance with established procedures by monitoring denied claims appeal processing and financial reconciliation.
  • Serves as regional consultant in all aspects related to claims processing, medical review, and denied claims appeals.
  • Analyzes and reports denied claim data.
  • Educates employees concerning appealed claims procedures and trends analysis outcomes.
  • Establishes and maintains a denied claims database which includes denied claim patient demographics, claim details, appeal reconciliation, and closure data.
  • Queries facilities monthly for accuracy of denied claim information.
  • Enters accessed denied claim information in database.
  • Updates database as denied claim progresses through the appeals process.
  • Maintains communication at least monthly with regional management regarding denied claim appeals status.
  • Maintains current knowledge of claims processing and medical reviews employed by fiscal intermediary and Medicare integrity programs.
  • Maintains current knowledge of denied claims appeals outcomes and explanatory factors.
  • Serves as resource to regional managers and staff regarding appeal processes.
  • Seeks expert clinical or legal advice and serves as information conduit to regional managers and staff.
  • Facilitates and assists with the coordination of large-scale appeals (FMR, CMR).
  • Ensures that medical records secured for the appeals process are preserved confidentially.
  • Monitors trends from denied claim causes, appeal outcomes, and financial reconciliation.
  • Systematically analyzes claims data, medical review information, appeal stage outcomes, and financial reconciliation.
  • Produces and analyses monthly and quarterly data summation reports and graphs for regional and senior management.
  • Review reports from CMS and other reporting agencies to track Organization Quality Measures and work with the regional team to implement plans of correction for continuous improvement. 
  • Review care plans for accuracy and completion via random audits implement education based on findings with the regional team. 
  • Hold quarterly meetings with the Regional Clinical Reimbursement MDS Specialist to review expectations and changes that may arise in the industry. 
  • Randomly audit MDS assessments and ensure accuracy and timeliness of completion.
  • Ability to work in a constant state of alertness and in a safe manner at all times.
  • Performs all other duties as assigned.

 

 

This opening is for Mon - Fri, shift 8:30 AM - 5 PM. 

Job Requirements

Qualifications:

  • Must possess a current, unencumbered, active license to practice as a Registered Nurse (RN) in Florida;
  • Must be able to read, write, speak, and understand the English language;
  • Must be at least eighteen (18) years of age;
  • Must meet the Education and Experience requirements outlined below; 
  • Must be a supportive team member, contribute to and be an example of team work and team concept.
  • Must possess the ability to make independent decisions when circumstances warrant such action.
  • Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
  • Must be able to work in a constant state of alertness and in a safe manner at all times.

 

Education and Experience:

  • Must possess, at a minimum, a Nursing Degree/Diploma from an accredited nursing school, college or university;
  • Preferred two (2) years, at a minimum, of experience in a hospital, nursing care facility, or other related health care facility;
  • One (1) year of MDS experience preferred;
  • Valid RN license in the State of Florida.

Avante offers a premium salary & benefits package!

 

Avante Group, Inc

4601 Sheridan St., Suite 500

Hollywood, FL 33021

 

Avante provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, Veterans' status, national origin, gender identity or expression, age, sexual orientation, disability, gender, genetic information or any other category protected by law.  In addition to federal requirements, Avante complies with applicable state and local laws governing non-discrimination in employment in every location in which the company has facilities.  This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. 

 

Avante expressly prohibits any form of workplace harassment based on race, color, religion, sex, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, Veterans' status or any other category protected by law.  Improper interference with the ability of Avante's employees to perform their job duties may result in discipline, up to and including, discharge.