Allegheny Health Network Careers

Job Number: DURRC
Location: Allegheny Center
Department:  Case Management
Status: Full time, 40 hours/week
Shift: M-F,  8-4:30pm with weekend rotation.This position will require travel to assigned AHN entities as needed.

Welcome to Allegheny Health Network (AHN), a proud member of Highmark Health. Working as an integrated delivery system based in western Pennsylvania, AHN includes seven hospitals, three health + wellness pavilions, and hundreds of primary and specialty care offices, with more than 1,700 physicians, 17,000 employees, and 2,000 volunteers.

AHN’s nationally recognized doctors and healthcare professionals are continuously exploring and advancing innovative treatments to provide accessible and quality care. Comparion Medical Analytics ranked many of our programs among the best in the country, according to its 2016 National Quality ratings. Also, other organizations, including Thomson Reuters and Consumer Reports, have recognized our dedication to excellence and world-class medicine.

AHN is a national leader in the healthcare industry, committed to improving health and promoting wellness in our community, one person at a time. We are dedicated to continually learning and exploring new, better, and creative ways to serve our patients, our employees and our community.

 
Job Summary:
Responsible for obtaining insurance precertification/recertification, functioning as a liaison with third party payers, communicating clinical information to the insurance companies as requested, addressing and resolving any actual or potential denials, and functioning as a member of the care coordination team.

Job Responsibilities:

Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and
placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party
payer guidelines.

Obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements.

Documents, monitors, intervenes/resolves, and reports clinical denials/appeals and retrospective payer audit denials; collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor, and third party payers, etc.

Maintains a working knowledge of care management, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental/commercial payer guidelines.

Adheres to the policies, procedures, rules, regulations, and laws of the hospital and all federal and state regulatory bodies.

Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
Assumes responsibility for AHN required continued education and own professional growth.

Performs other duties as assigned or required.

Requirements:

BA/BS and nursing diploma required. Current employees grandfathered
New hires must complete degree within 24 months of hire.

Current PA licensure as a RN.

Nationally recognized Care Management Certification within 5 years of start date (3 years for currently employed UR's) required.

CPR

Minimum of 2-3 years nursing experience with a minimum of one (1) year experience in Utilization Management required.

Experience in case management, discharge planning and/or the application of InterQual criteria preferred.