Offer summary

Qualifications:

Associate degree in Nursing or bachelor's degree in nursing with NCLEX for Registered Nurses or Licensed Practical Nurse with NCLEX-PN for LPN., Three years of experience in direct patient care or hospital revenue cycle and authorization management., Preferred: Registered Nurse or Licensed Practical Nurse certification and prior medical necessity review experience., Extensive knowledge of medical terminology, coding systems, and the managed care industry..

Key responsabilities:

Evaluate requested services to determine medical necessity using payer criteria and clinical guidelines.

Review medical records to support the clinical picture and severity of patient care.

Communicate medical necessity effectively to applicable payers and stay updated on clinical guidelines.

Research and prepare appeal files for preservice clinical denials and track denial issues for process improvement.

Job description

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The Medical Necessity examines the medical records and performs front end medical necessity review of ordered services through the pre-authorization services. In this role, the associate will assess provider education opportunities and coordinate feedback sessions established by authorization requirement and payer policies. This role will serve as a subject matter expert (SME) as related to medical necessity for the revenue cycle department. This position will collaborate with other departments, as necessary to ensure medical necessity is established for services requested/rendered.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Associate degree (ASN) in Nursing OR bachelor’s degree in nursing and passing the National Council Licensure Examination (NCLEX) for Registered Nurses OR Licensed Practical Nurse and passing the NCLEX-PN for LPN

EXPERIENCE:

1. Three (3) years’ experience in direct patient care experience OR hospital revenue cycle and authorization management experience

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Registered Nurse or Licensed Practical Nurse

EXPERIENCE:

1. Prior medical necessity review experience preferred

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Evaluates the requested service to determine medical necessity, utilizing payers’ criteria and industry standard clinical guidelines

2. Review documentation in medical record that support the clinical picture/severity of illness/complexity of the patient care rendered to the patient.

3. Uses clinical knowledge to identify potential clarifications of the record

4. Assures effective communication of medical necessity to the applicable payer

5. Responsible for staying up to date on payer clinical guidelines and authorization requirements

6. Perform a determination if the preservice denial requires appeal or a peer-to-peer review

7. Research and prepare appeal files in response to preservice clinical denials.

8. Resolve clinical denials, which include researching and reviewing payer guidelines, writing, and submitting appeals with supporting documentation if required

9. Analysis of clinical denials including identification of root cause to provide feedback to the physicians and or clinical departments

10. Track and trend denials issues for escalation to leadership to assist with process improvement

11. Actively participates in process improvement initiatives, working with a variety of departments and multidisciplinary staff.

12. Effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment

13. Consistently demonstrate ability to serve as a role model and change agent by promoting the concept of teamwork and the revenue cycle process continuum of high performing teams

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to sit for long periods of time.

2. Ability to lift, push or pull approximately 25-80 pounds.

3. Visual acuity must be within normal range

4. Must have manual dexterity to operate keyboards, fax machines, telephones, and other business equipment

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment

SKILLS AND ABILITIES:

1. Extensive knowledge of medical terminology, anatomy and pathophysiology, pharmacology and ancillary test results

2. Proficient understanding of medical coding systems effecting the adjudication of claims payment. These include ICD-10,CPT,HCPCS,DRG,APG,APC,and revenue code

3. Knowledge of the managed care industry including payer structures, administrative rules, and government payers.

4. Demonstrates critical thinking skills, able to assess, evaluate, and teach

5. Self-motivated and able to work independently without close supervision

6. Ability to develop and maintain professional relationships to foster positive outcomes and collaboration.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center: