Oversees the LBH clinical appeals daily operations and workflow. Serves as a clinical resource and lends guidance to the care management and clinical appeals staff. Assist the Director of Care Management with implementation, maintenance and evaluation of an integrated care management, denials management and clinical appeals program. Acts as a liaison to third party reviewers and coordinates and manages utilization issues concurrently and retrospectively as they relate to potential denials.
Requirements: Basic professional knowledge; equivalent to a Bachelor's degree; working knowledge of theory and practice within a specialized field. Bachelor's Degree in Nursing, Master's Degree Preferred. Minimum of two years experience in case management/utilization management/clinical appeals/discharge planning. Medical terminology; Nursing Process skills based on MD Nurse Practice Act; Critical thinking skills; Interqual and Milliman Utilization Review Criteria; Microsoft Office Suite; Basic computer skills; Cerner; Standard Office Equipment. Maryland Registered Nurse License; American Heart Association CPR Certification; Case Management Certification Preferred. Demonstrates the ability to follow verbal instructions, as well as the ability to communicate effectively verbally and in writing.