RN Healthcare Review Analyst (Healthcare)

Position Summary
The RN Healthcare Review Analyst administers the Medical Staffs program of quality improvement activities of Peer Review and provides clinical information to obtain authorizations of contracted and non-contracted entities.

Essential Job Functions/Accountabilities
Handles daily review of potential claims with third party payers, employer groups, physician, patients and family members, and departments.

Prepares, presents, and reviews variations requiring Peer Review with physician reviewers and prepares cases for further medical staff departmental review.

Analyzes and intervenes with physicians on variations in care to optimize medical care and hospital resource utilization.

Facilitates appeals of denied patient hospital stays by collaborative writing of letters in an attempt to secure payment for acute hospital level of care. Outcomes are entered into the AllScripts and/or HMS Graphical systems.

Uses data to measure outcomes, track quality and enable improvement.

All other duties not specifically assigned.

Position Requirements
Education: Graduate from an approved School of Professional Nursing. B.S.N. or other related professional degree may be substituted for up to two years of the experience.

Experience: Three (3) years recent professional nursing experience; two (2) years of which has provided a combination of medical, specialty care, and/or surgical experience in an acute care setting.

Technical Skills: N/A

Certifications/Licenses/Registrations: Current license to practice as registered nurse in the State of Ohio.