Registered Nurse (RN) | Utilization Review at Abarca Health

Sioux Falls, South Dakota, United States

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$63,440 – $95,080Compensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Registered Nurse (RN) licensure
Ability to work rotating days/evenings/nights/weekends/holidays, including four 10-hour shifts (0630-1700 / 1030-2100) and every 5th holiday/weekend rotation (0900-1900)
Must live within 2 hours of Sioux Falls
Ability to attend 6-8 weeks of in-person training in Sioux Falls
Visual acuity adequate to perform position duties
Ability to communicate effectively, hear, understand, and distinguish speech and other sounds

Responsibilities

Review clinical documentation in the hospital electronic medical record for current admissions, continued stays, and retrospective inpatient/observation level of care appropriateness
Prompt admitting providers regarding missing, unclear, or conflicting clinical documentation in the EMR that does not support inpatient admissions, when necessary
Utilize third-party clinical guidelines for level of care reviews (first-level review) and refer cases to internal/external physician advisor for second-level determinations if documentation does not support the ordered level of care
Report relevant clinical information to third-party payers via websites, fax, or telephone to support admission, continued stay, and retrospective reviews
Maintain accurate documentation of activities in the UR Module and various systems, adhering to quality and production standards per internal guidelines/policies
Maintain knowledge of payer-specific level of care requirements, inpatient only list, authorization requirements, documentation needs, non-covered services, and waivers; serve as a resource and provide subject matter expertise to providers, clinics, and organization members
Assist leaders with payer trending, audits, and other assigned tasks
Coordinate payer Peer-to-Peer appeals for commercial/managed care payer admission/concurrent level of care denials
Collaborate with Clinical Appeals Specialist to track and trend Utilization Review-related denials/appeals
Assist with collection and maintenance of records for Compliance, Joint Commission, OSHA, or legal requirements
Collaborate with clinicians and financial team members (e.g., Pre-anesthesia, Surgery Scheduling, Clinical Departments, physicians, payers, Patient Access, Health Information Management, Case Management)
Ensure signed inpatient order on account for all Medicare inpatient-only procedure cases
Maintain awareness of business of medicine and transitional healthcare changes (e.g., value-based purchasing, bundled payments, accountable care organizations, readmission reduction program)

Skills

Utilization Review

Level of Care Determination

Clinical Documentation Review

Electronic Medical Record (EMR)

Insurance Payment Requirements

Medicare Inpatient Orders

Case Management

Value-Based Purchasing

Abarca Health

Pharmacy Benefit Management services provider

About Abarca Health

Abarca Health provides Pharmacy Benefit Management (PBM) services, focusing on flexible and user-friendly solutions for health plans, employers, and government programs like Medicare and Medicaid. Its main product, the Darwin platform, allows clients to quickly implement and modify benefit designs while ensuring compliance with regulations. Abarca Health manages over $5.3 billion in drug spend and processes 100 million prescription claims annually, offering additional services like home delivery for prescriptions. The company's goal is to deliver exceptional service and innovative solutions in the PBM market.

Aventura, FloridaHeadquarters

2005Year Founded

VENTURE_UNKNOWNCompany Stage

HealthcareIndustries

501-1,000Employees

Benefits

PTO

Parental leave

Work flexibility

Health insurance

Wellness stipend

401k

Tuition reimbursement

Leadership development programs

Risks

Increased competition from Amazon Pharmacy and Mark Cuban's Cost Plus Drug Company.

Growing focus on specialty drugs may require platform adaptation.

Shift towards price transparency could pressure Abarca's pricing models.

Differentiation

Abarca Health's Darwin platform is highly adaptable and user-friendly.

The company offers innovative programs like Triple S en Casa for home delivery.

Abarca Health ensures compliance with ever-changing healthcare regulations.

Upsides

Abarca transitioned two million members to Darwin in 18 months, showing operational efficiency.

Collaboration with Blue Shield of California boosts Abarca's reputation in the PBM sector.

Recognition as a top IT workplace attracts top talent, driving innovation.

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