Position Summary:

Enhances continuity of patient care by providing liaison between assigned populations, providers, hospitals, and physicians through the processing of medical determinations. To review, coordinate and facilitate all necessary information required from the payer or provider in order to render an informed determination on medically reasonable, necessary and appropriate clinical care.

Roles and Responsibilities:

• Primary role as an appeal or claim reviewer. Perform pre-service appeals, post service appeals, and post service claim reviews, and provide documented recommendations based on the use of appropriate clinical guidelines.

• Review initial evaluation and all additional clinical documentation against clinical standards, applicable state regulations and relevant treatment guidelines.

• Review and comply with treatment guidelines and clinical review criteria to assist in determining the appropriateness of services.

• Clinical nurse reviewers cannot render a recommendation or a determination for an appeal, however, may assist with providing appeals and claims recommendations to the payer, and in the notification process for delegated appeals.

• Assist manager and clinical staff in quality improvement projects to provide instructive feedback to clients and providers within scope of practice.

• Resolves patient care issues by working one-to-one with clients, community providers and staff to resolve issues in determination process.

• Support non-clinical staff with clinically related questions or issues that arise within scope of practice.

• Meets medical operational standards by contributing information to strategic plans and reviews, implementing

production, productivity, quality, and customer-service standards; resolving problems; identifying system improvements.

• Educates clients and community provider’s team by attending nursing team meetings; providing input relating to clinical concerns for individual patient requests.

• Provides information by responding to queries of payers, physicians, and their practice staffs; sorting and distributing messages and documents; answering questions and requests; preparing information for recommendations and determinations; maintaining databases.

• Improves quality results by studying, evaluating procedures and processes, recommending changes to services if needed.

JOB DESCRIPTION

• Serves and protects the company by adhering to URAC and NCQA standards, professional standards, policies and procedures, federal, state, and local requirements, and professional and licensing standards.

• Contributes to company effectiveness by identifying short-term and long-range issues that must be addressed; providing information and commentary pertinent to deliberations; recommending options and courses of action; implementing directives.

• Attend meetings and training.

• Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations.

• Enhances company reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.

• Follows company policies and procedures and conducts annual performance reviews in a timely manner.

• Acts as a liaison for interdepartmental communication.

• Respects and maintains HIPAA confidentiality guidelines.

• Other duties as directed.

Education, Experience and Licensure:

Internal candidates must have at least 6 months in current role or prior claims and/or appeals experience

No corrective action or attendance issues on file

• Active and unrestricted Registered Nurse or License Practical Nurse licensure in any State in the United

States. Some states may require an active and unrestricted nursing license.

• Diploma of nursing from an accredited school required.

• Bachelor’s Degree in a health related field preferred.

• Minimum of 5 years’ experience in healthcare operations preferred.

• Excellent verbal and written communication skills. Ability to foster a cohesive working environment.

Preferred Professional Competency:

• RN: National Certification in specialty area (i.e. Orthopedics, Cardiology, etc.)

• LPN: Experienced in area of UM focus and working within a managed care environment.

Preferred Skills:

Creating a Safe, Effective Environment, Health Promotion and Maintenance, Nursing Skills, Verbal Communication,

Listening, Confidentiality, Dependability, Emotional Control, Medical Teamwork.

Strong organizational skills; commitment to customer service; ability to problem solve; strong presentation skills throughout all levels of the organization. Must be able to foster a positive and productive work environment with ability to lead, build teams and motivate staff. Proficient in Microsoft Word, Excel and Outlook.

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