Employer Industry: Healthcare

Why consider this job opportunity:
- Estimated salary range of up to $114,999.25 per year, depending on experience
- Opportunity for career advancement and growth within a leading healthcare organization
- Supportive and collaborative work environment with a focus on patient care
- Chance to make a positive impact on patient outcomes and healthcare delivery
- Recognized as one of Fortune’s 100 Best Companies to Work For, contributing to a positive workplace culture

What to Expect (Job Responsibilities):
- Function as a senior expert consultant for Case Management to ensure high-quality patient care and efficient resource utilization
- Evaluate denials and non-certified days from third-party payors to determine appropriateness and feasibility of appeal
- Consult with attending physicians and case managers to formulate secondary and formal appeals using medical management tools
- Serve as an expert internal consultant for multiple departments related to regulatory and billing requirements
- Review all surgery cases pre and post-procedure to ensure appropriate authorization and medical necessity is present in the EMR

What is Required (Qualifications):
- Bachelor’s degree
- Registered Nurse license and one of the listed certifications (e.g., AACN Acute/Critical Care Nursing, ANCC Nursing Case Management)
- Minimum of 2 years of hospital or payor Utilization Management review experience required
- Excellent written, interpersonal communication, and negotiation skills
- Strong critical thinking, organizational, and time management skills

How to Stand Out (Preferred Qualifications):
- 3 years of hospital clinical experience preferred
- Current working knowledge of payor and managed care reimbursement
- Familiarity with CPT, ICD-9 & -10, and DRG coding preferred
- Strong ability to research evidence-based practices
- Case management or utilization review/surgery pre-anesthesia experience preferred

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