Clinical/Utilization Review Nurse

• Manages complex and robust queue according to Aspirion and client needs. Queue size varies weekly.
• Reviews insurance denials, including but not limited to, medical necessity denials, patient status denials (i.e., Inpatient vs. Outpatient Observation), level of care denials (i.e., bed type), length of stay denials (including stays over a month long), readmission denials, experimental denials, clinical validation denials, and/or authorization denials.
• Reviews and utilizes clinical criteria, including but not limited to, InterQual, Milliman Care Guidelines (“MCG”), UpToDate, Medicare Policies, and State Specific Clinical Criteria.
• Drafts clinical summaries, including but not limited to, arguing against an insurance denial, confirming an insurance denial, or reviewing a clinical determination.
• When performing clinical reviews, monitors hours expended on a single account to ensure the time invested is commensurate with the account’s potential reimbursement and check in with Managing Attorney when time expended exceeds average hours for type of review
• Identifies and tracks common trends and issues for reporting to the clients.
• Collaborates with Aspirion attorneys via in person meetings, phone, and/or email.
• Attends Clinical Team Meetings, All Company Meetings, Education Opportunities, Trainings, and other potential meetings