Job Description
Position Purpose This position is responsible for the performing advanced complex clinical reviews of patient accounts. This position provides expertise in care coordination, utilization management, payer issues/requirements, grievance and reconsideration process, and facilitating problem resolution to ensure the financial wellness of the organization.
This position documents, researches and resolves reconsideration and grievance cases filed by members, providers and external agencies. The incumbent will compare clinical and financial records to ensure the documentation provided supports the patient charges Identification, tracking, and reporting of trends/issues. The incumbent coordinates special projects and programs as needed, works independently, and is able to be a team player who builds effective inter-departmental working relationships throughout the Health System.
Nature and Scope The RN Clinical Review Specialist will:
•Conduct review of clinical-based denials (i.e. Medical Necessity, Level of Care) for all payors within required time frames (as determined by individual payor), utilizing clinical criteria sets, knowledge of payor regulations (i.e. Medicare, Nevada Medicaid, Managed Care Payors), and considerable clinical judgment, to determine appropriateness of care.
•Develop responses to payor denials including the provision of supporting clinical evidence of appropriate, medically necessary care to payors in the form of written appeals.
•Provide expertise, direction, and feedback to Health System leadership regarding complex case management issues and trends.
•Conducts clinical review and preparation of responses for Medicare Additional Documentation Requests (ADR's), Recovery Audit Contractor ADR's, and other authorized Medicare vendor documentation requests. Ensure all required documentation is present and provides feedback to the entire Renown Health Network and Care Coordination/Utilization Review staff on potential denials from these requests.
•Research and analyzes Medicare observation stays greater than 48 hours to ensure appropriateness of setting, level of care, medical necessity, and billing accuracy.
•Perform clinical charge reviews of organ donation accounts, using clinical knowledge and judgment to ensure hospital charges are accurately assigned to the appropriate patient/organ donation account(s)
•Perform clinical charge reviews of split coverage accounts (i.e. cosmetic/bariatric surgeries with insurance covered services), using clinical knowledge and judgment to ensure charges are accurately assigned between the cosmetic/bariatric service and the insurance-covered service.
•Perform audits of patient disputes of hospital charges. Evaluates the billed charges on a claim against the clinical documentation in the medical record to determine accuracy of items billed. The nurse will then provide written communication to the patient summarizing the patient's perception of the issue and providing determination and rationale for charges incurred, coordinates charge corrections when necessary to ensure billing accuracy.
•Perform clinical charge review of cancelled surgery claims to ensure billing accuracy.
•Research Medicare outpatient claims billed with Medicare-defined inpatient only procedures to ensure accuracy of physician orders in comparison to the hospital's billed charges.
•Review, triages, and prioritizes cases to meet all required turnaround times.
•Document all activities in the Epic and ComplyTrack systems.
•Identify Epic system improvement opportunities related to the clinical documentation and reporting process to ensure appropriate admission status, level of care, and external agency reporting requirements. Identifies ComplyTrack system improvements as found.
•Analyzes data from above reviews for root cause and offers suggestions for improvement during the feedback process.
•Prepares reports, data, or other materials for Care Coordination committee presentations or other teaching opportunities within the Renown Health System.
•Performs other duties as assigned
This position does not provide direct patient care.
Disclaimer The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Minimum Qualifications Requirements - Required and/or Preferred
Name Description Education:
Must have working-level knowledge of the English language, including reading, writing and speaking English. Bachelor's Degree in Nursing is preferred.
Experience:
3 years of Case Management, Utilization Review, and/or Medical Review experience required.
Managed care experience in case management, quality management, utilization review and/or medical review OR any combination of education/experience, which would provide an equivalent background required.
Knowledge of case management, utilization review, quality management and/or medical review techniques required. Understanding of criteria-based clinical decision support tools preferred.
Understanding of ICD-9-CM, CPT, & HCPCS coding structures preferred.
Claims processing knowledge preferred.
Working knowledge of healthcare regulations such as HIPAA, EMTALA, ERISA, and JCAHO as related to work experience required.
License(s):
Ability to obtain and maintain a State of Nevada RN license.
Certification(s):
Certification in Case Management (CCM) preferred.
Computer / Typing:
Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.
Computer literacy, including word processing, spreadsheet applications, database management and graphics experience required. Experience with Microsoft Office required.
Job Tags
For contractors, Work experience placement,