Department: Recruitment

Employment Type: Full Time

Location: MedTrust - Oklahoma City

Description
A CR/UM nurse monitors and manages current inpatient care to ensure medically necessary care is provided and then evaluates healthcare claims submitted by providers to ensure medical necessity, accuracy, and compliance with MedHealth policies. The CR/UM nurse also reaches out to hospitals and specialty providers to negotiate aggressive rates. This is done in coordination with our corporate legal, who will memorialize the approved negotiated rates. Key responsibilities include daily contact with hospitals when a MedHealth patient is an inpatient, review medical records and clinical data, coordinating with healthcare providers, and communicating with providers to reprice claims as negotiated approve or deny services. This role is crucial for controlling costs and ensuring patients receive appropriate evidence-based care. The CR/UM nurse must have a current nursing license, minimal 1 year experience in CR/UM, and thorough knowledge of medical terminology, strong knowledge of CR/UM standards, working knowledge of claims coding to ensure we aren't overbilled, and a willingness to negotiate favorable rates with community providers/hospitals. knowledge of medical coding standards. Familiarity with claims processing, electronic medical record (EMR) systems, and utilization review platforms like InterQual or MCG is required. Strong analytical thinking, attention to detail, and effective written and verbal communication skills make someone stand out in this role. These capabilities ensure accurate and efficient patient care and subsequent claim assessments, minimizing errors and supporting fair reimbursement within regulatory and negotiated guidelines.
Key Responsibilities

• Monitor Inpatient Care: Monitor care when a MedHealth patient is hospitalized to ensure proper care is provided and the patient is returned to the MedHealth facility as soon as medically appropriate.
• Review claims and medical records: Assess claims for accuracy in coding and determine if services align with established clinical guidelines and industry/MedHealth policies.
• Ensure medical necessity: Verify that proposed treatments and procedures are medically necessary and appropriate for the patient's condition.
• Determine coverage: In coordination with our Chief Medical Officer, make coverage decisions for specific procedures or treatments based on their review.
• Communicate with stakeholders: Collaborate with physicians and other healthcare professionals to discuss care plans and resolve issues.
• Manage appeals and denials: Investigate and respond to claim denial appeals, when necessary, which will involve negotiating with providers.
• Ensure compliance: Stay up to date with federal, state, and local regulations to ensure compliance.
• Monitor quality and efficiency: Track the utilization of healthcare services to identify trends and areas for improvement while maintaining quality of care.
• Negotiate Rates: Reach out to community providers and hospitals and negotiate the most favorable payment rates.
• Other tasks as assigned and in line with the skills and licensure.

Work is 8am to 5pm M-F in our Oklahoma Office. Includes a 60-minute lunch break.
Skills, Knowledge and Expertise Skills & Qualifications

• Active registered nurse (RN) license.
• Experience in acute care nursing or case management.
• Strong knowledge of clinical guidelines, correctional healthcare, and healthcare delivery systems in general.
• Excellent analytical, documentation, and critical thinking skills.
• Effective communication and interpersonal skills.
• Proficiency with electronic health records and computer skills.
• Knowledge of or willingness to learn insurance coding is a plus