Job Description
Overview:
Works within the Authorization Services team, responsible for retrospective authorizations of inpatient and outpatient services performed. This role will conduct medical necessity reviews utilizing established medical criteria to aid in reimbursement of services performed. A minimal portion of this role may include telephonic reviews of inpatient hospital admissions, depending on state requirement, requiring extraction of clinical information from the patient record necessary to justify care rendered in the Inpatient and Outpatient setting to meet medical necessity for reimbursement.
The hours of operation are Monday through Friday 8 am to 5 pm eastern standard time.
Responsibilities:
• Provides retrospective clinical review according to state and medical necessity criteria using InterQual guidelines.
• Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process.
• Adheres to the department standards for productivity and quality goals. Ensuring accounts assigned are worked in a timely manner based on the payor guidelines.
• Performs follow-up on initial denials received from payors on retrospective clinical reviews by first level of appeal submission.
• Ensure Diagnosis and Procedure codes align with services performed and communicate discrepancies to appropriate contacts per workflow process.
• Perform other related tasks as assigned by supervisor or manager and maintains department productivity and quality measures.
• Attends regular staff meetings, conducts self in a professional manner at all times, and completes assigned work objectives and projects in a timely manner.
Knowledge, Skills and Abilities:
• Knowledge of UM principles and practices, involving medical and behavioral case management, disease management, utilization and pharmaceutical management desired.
• Skilled with clinical knowledge and experience in the treatment of human injuries, diseases, and deformities including symptoms, treatment alternatives, drug properties and interactions, behavioral health conditions and preventive health guidelines.
• Demonstrated ability to lead, communicate, problem solve, and work effectively with people.
• Excellent organizational skill with the ability to manage multiple priorities.
• Work independently and handle multiple projects simultaneously.
• Knowledge of applicable state, and federal regulations.
• In-depth knowledge of InterQual and other references for length of stay and medical necessity determinations.
• Ability to take initiative and see tasks to completion.
• Computer Literate (Microsoft Office Products).
• Excellent verbal and written communication skills.
• Ability to maintain attendance to support required quality and quantity of work.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
• Skilled at establishing and maintaining positive and effective work relationships with coworkers and clients.
• Critical thinker, able to make decisions regarding medical necessity independently
EDUCATION:
• High School Diploma or equivalent required.
• Completion of an accredited (RN) -OR- an accredited (LVN) program required.
• Bachelor's degree in nursing or health related field preferred.
EXPERIENCE:
• Minimum of 3 years clinical practice experience required.
• 2 years utilization management and/or case management required.
REQUIRED CERTIFICATIONS/LICENSURE:
• Active, unrestricted State Registered Nursing license or state Licensed Vocational Nursing license in good standing required.
o Must hold and maintain this certification(s) as a professional in the state of residency.
Job Tags
Monday to Friday,