Job Description Responsible for utilizing nationally recognized criteria sets and authoring clinical appeals to be submitted to appropriate payers in order to secure recovery of denied dollars. Provides leadership with examples of trends which are communicated to the clinical department leadership for process improvement opportunities. Requires knowledge of regulatory compliance related to Medicare, Medicaid and commercial payers to ensure compliance with medical necessity and/or benefit determination. This clinical position will support denial resolution across the organization, hospital and clinics. Utilizes clinical skills to assist in the facilitation of referrals, authorizations and financial clearance for clinical procedures and treatment regimens. Responsible to contact payer, provider and provider staff for assistance in rescheduling practices including medical information gathering, confirmation of medical necessity and urgency determinations. Prepares medical cases for payer peer to peer review. Assists with communication and training initiatives related to referral/pre-authorization performance improvement initiatives across Kootenai Health. Works collaboratively with internal and external stakeholders to assess workflow processes, identify insufficiencies, investigate root causes and work to implement change to ensure timely authorizations. Understands the business of the department and how the work impacts the overall revenue cycle. Recognizes out of the ordinary situations and works with stakeholders to improve processes. Relies on experience and judgment to plan and accomplish goals. A degree of creativity and latitude is expected. Performs other related duties as assigned.
Minimum Qualifications: State of Idaho Registered Nurse or licensure pending as documented by temporary licensure OR current RN licensure from a state participating in the "multistate privilege to practice" compact with Idaho. BSN required, MSN preferred 3. 5 years' experience in pre-authorization, care management, utilization review and/or clinical appeals 4. Proven experience with regulatory requirements for medical necessity for all payers. 5. Strong interpersonal skills and proven ability to function in a confidential and highly responsible manner. 6. Excellent computer skills and ability to learn multiple electronic medical record systems, including use of Excel, Word and PowerPoint office products.
Essential Job Functions (Physical Requirements): Regular and predictable attendance is an essential job function. Majority of shift spent sitting. No or very limited physical effort required. No or very limited exposure to physical risk. Communicate with patients, physicians, families and co-workers in person and on telephone. Work with equipment and manipulate equipment settings, computer keyboard, etc.
Work Environment: · Kootenai Health operates 24 hours per day each day of the year; operational needs of departments may require that you be available to work all shifts, weekends and holidays to meet the needs of the patients. · Work is normally performed in a typical interior work environment.
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