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INSURANCE REVIEW ANALYST LPN

Department:  CASE MANAGEMENT

Job Details

Req Id    64126 
Department    CASE MANAGEMENT 
Shift   Days
Shift Hours Worked    7.50 
FTE    
Work Schedule    SEMC NU 7.5 HR 
Employee Status    A1 - Full-Time 
Union  Non-Union

Job Summary

The Insurance Review Analyst works under direction supervision of the Utilization Review Supervisor.  Providing system support to the Utilization Review process.  Gathers clinical data to be provided to the insurance company for their review.  Aggregates data for the reporting of reviews and denials at designated meetings.  Communicates with the entire Case Management team to ensure everyone is aware of the patient’s payer source and to ensure that approval for appropriate reimbursement for services is provided for the patients. 

Core Job Responsibilities

Provides clinical information to the Insurance Companies as requested via telephone, fax or mailed, to obtain authorizations and reimbursement for services.

Informs the Case Manager/Social Worker, Physician and other relevant interested parties of any potential denials from the Insurance Companies.

Contacts and assists the physicians in appealing denials via    telephone contact or in writing as appropriate.

Assist the appeals process for insurance denials as requested by the Utilization staff. 

Maintains documentation of the insurance review, approvals/denials in the Midas system.

Gathers prospective/retrospective information from the medical record to assist the Utilization Nurse in reviewing the medical record to assist in requested insurance review process.

Provides insurance review data to the Utilization Supervisor to report to the Length of Stay Committee to include volume of reviews and denials.

Provides clerical support to the physicians, Case Management and Utilization staff as needed.

Maintains the Insurance Review files in Midas.

Responds to the Patient Access requests for information and for direction on insurance reviews to be sent.

Keeps the Utilization Supervisor/Director of Case Management & Utilization apprised of concerns and potential risks associated with the insurance review process.

Perform other associated tasks and activities at the direction of the Utilization Supervisor and the Director of Case Management & Utilization Management.

Education/Experience Requirements

Preferred: 2 year degree; 3 years Acute Care experience and/or 1 year of Insurance, Utilization Reviewer or Case Management experience.

Licensure/Certification Requirements

Preferred: LPN

EOE AA M/F/Vet/Disability

Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability.

Successful candidates might be required to undergo a background verification with an external vendor.


Nearest Major Market: Utica