JOB DESCRIPTION: Responsible for the utilization review and technical appeal of clinically related denials (concurrent and retro) achieving optimal financial outcomes for the hospital. Expert utilization and application of InterQual® and Milliman® criteria. Represents Saint Joseph's providing formal appeals via letter and phone to managed care payers. Appeal processes include but are not limited to review of utilization review, billing, coding, charging, and clinically related technical errors. Creates and designs databases documenting clinical and technical denial information which can then be further analyzed. Provides denial reports on a monthly, quarterly, and requested basis to the Care Management Department, Patient Financial Services, Managed Care Contracting, Revenue Cycle, and hospital leadership including the CEO. Reports reflect hospital trends regarding patterns of denials and outcomes of appeals using a data driven approach. Uses financial analysis to develop proactive strategies for denials reduction. Coordinates activities and strategies with the Care Management Department, Patient Access, Billing, Managed Care, and Physician Advisors. Expert knowledge of every current Saint Joseph's managed care contract, informing the Managed Care Contracting Department of patterns, trends and critical incidents related to payment denials. Represents Saint Joseph's in identification, negotiation, and problem solving in conjunction with the Managed Care Contracting Department. Prioritizes assignments to avoid financial risk. Serves as a financial resource to team. Expert knowledge base regarding payer regulations and industry trends.
MINIMUM QUALIFICATIONS: Minimum of 3 - 5 years of varied hospital and Utilization Review experience. Includes minimum two years experience in insurance setting with focus on Managed Care (preferred). Expert in database functions and spreadsheets. Graduate of an accredited School of Nursing and licensed as a Registered Nurse in the State of Georgia. Certification as CCM, HIAA, HFMA and/or Inpatient Coding preferred.
PHYSICAL REQUIREMENTS: 1-10 lbs 0-33% of the work day (occasionally), negligible 34-66% of the workday (frequently), negligible 67-100% of the workday (constantly). Lifting 10 lbs max, carrying of small articles such as dockets, ledgers, files, small tools, occasional standing & walking, frequent sitting, close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.
ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure, Bio-hazardous waste. chemicals/gases/fumes/vapors, communicable diseases, electrical shock, floor surfaces, hot/cold temperatures, indoor/outdoor conditions, latex, lighting patient care/handling injuries, radiation, shift work, travel may be required, use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.
Must have an RN nursing background, Graduate of an accredited School of Nursing and licensed as a Registered Nurse in the State of Georgia and Utilization Review experience.