Position Summary / Career Interest:

Duties can include working with pre-certification / authorization / denials teams to assist in obtaining up front authorization for services rendered. Clinical expertise including chart review, peer to peer requirements, and appeal requirements are all required skills/ knowledge needed to perform the job responsibilities. Will assist with denial management and resolution. Will collaborate with HIM, PFS, Case Management and multiple clinical departments to resolve a variety of account problems related to authorization of services and account resolution. Duties in supporting the Clinical Trials business line include reviewing protocols to assist in ensuring services being billed as standard of care are evidenced based and meeting industry guidelines for being billed as SOC. Also assists in the clinical trials area to help ensure all services rendered as part of the trial are identified.  

Responsibilities and Essential Job Functions

• Responsible for decreasing denied and inappropriately paid claims attributable to clinical and/or administrative reasons.
• Performs utilization review for correct patient setting (IP, OP, Observation) and correct patient status: Medical Necessity, Charge Audit reviews, Missing charges, Undocumented charges, completes documentation to support services per peer standards. Reviews high dollar & high-risk areas like transplants, Cancer Center and Cardiology.
• Uses clinical expertise to perform ongoing reviews of medical record documentation and clinical pertinence in accordance with peer standards and Medicare Regulations.
• Assists in tabulations of results and reports to management. Assists with a variety of clinical reviews as requested by members of the healthcare team and provides feedback. Supports process improvement activities to assure medical record compliance with regulatory and accreditation bodies.
• Collaborates with HIM coding staff and Patient Financial Services to investigate and resolve a variety of account problems related to clinical information.
• Monitors process effectiveness to identify trends and improvement opportunities. Assists with the development, implementation, and testing process improvement plans.
• Assists with quality improvement initiatives across the continuum of care as indicated: Authorization, Eligibility, Medical Necessity, Utilization Review, Documentation, Patient Status.
• Evaluates and resolves issues related to the revenue cycle including medical documentation, utilization review and medical necessity.
• Assists with documentation support and issue resolution in areas of charge capture, charge master, coding, claim submission and information system.
• Works with various departments and physician offices as necessary to resolve revenue cycle process conflicts.
• Provides training to improve revenue cycle processes.
• Recommends policies and procedures improvements to increase efficiencies in coordination with other areas of the department and with other departments.
• Provides necessary education and feedback to medical and ancillary staff to improve the overall quality of medical record documentation appropriate patient status orders, and clinical pertinence.
• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.

Required Education and Experience

• Bachelor Degree Nursing
• 2 or more years experience in utilization review, clinical review, or authorizations

Preferred Education and Experience

• EPIC experience

Required Licensure and Certification

• Licensed Registered Nurse (LRN) - Multi-State - State Board of Nursing Current State RN license

We are an equal employment opportunity employer without regard to a person’s race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, ancestry, age (40 or older), disability, veteran status or genetic information.