About the position

The Revenue Cycle Clinician for the Appellate Solution is responsible for: Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review Preparing and documenting appeal based on industry accepted criteria.

Responsibilities

• Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
• Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual® or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits. Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
• Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process.
• Adhers to the department standards for productivity and quality goals. Ensuring accounts assigned are worked in a timely manner based on the payor guidelines.
• Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual®, VI, HPF, as well as competency in Microsoft Office.
• Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc.
• Serves as a resource to non-clinical personnel.
• Provides CRC leadership with sound solutions related to process improvement
• Assist in development of policy and procedures as business needs dictate.
• Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.

Requirements

• Demonstrates proficiency in the application of medical necessity criteria, currently InterQual®
• Possesses excellent written, verbal and professional letter writing skills
• Critical thinker, able to make decisions regarding medical necessity independently
• Ability to interact intelligently and professionally with other clinical and non-clinical partners
• Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms
• Ability to multi-task
• Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.
• Ability to conduct research regarding off-label use of medications
• Must possess a valid nursing license (Registered)
• Minimum of 3 yearsacute care experience in a facility environment
• Current, valid RN/ licensure

Nice-to-haves

• Medical-surgical/critical care experience preferred
• Appeals writing experience preffered
• Minimum of 2 years UR/Case Management experience preferred
• Managed care payor experience a plus either in Utilization Review, Case Management or Appeals
• Previous classroom led instruction on InterQual® or MCG products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred
• Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred

Benefits

• Medical, dental, vision, disability, and life insurance
• Paid time off (vacation & sick leave) – min of 12 days per year, accrue at a rate of approximately 1.84 hours per 40 hours worked.
• 401k with up to 6% employer match
• 10 paid holidays per year
• Health savings accounts, healthcare & dependent flexible spending accounts
• Employee Assistance program, Employee discount program
• Voluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.