Obtains complex pre-certification for all inpatient admission and pre-authorization for all outpatient diagnostic tests and performs an administrative support function. This job requires the application and interpretation of policies and procedures and the use of independent judgment in a medical setting. The purpose is to achieve the goals and to meet the denial rates set by Patient Access, the Medical Center and HSF to ensure minimum loss of revenue and maximum payment for services. Utilizing persuasive clinical arguments and tenacious communication skills, both oral and written, creates and submits appeal letters as needed to overturn denials. Utilizes critical thinking and root cause problem solving methodology to discern trends in payor behaviors and/or our clinical documentation/practice that need to be communicated back to departments or physicians in order to prevent continuing denials. Will also work with leadership and communicate routinely with our contracting department where payor behavior is inconsistent with our agreements. The ability to maintain a working knowledge of carrier contracts/changes and departmental policies and procedures is required.
** Please be aware that this job posting is exclusively available for team members transitioning from Community Health to UVA Health. Only those within this group are eligible to apply. Thank you for your understanding! **
- Utilizes clinical knowledge, payor contracts, medical review policies, supporting research, and any other relevant documentation to effectively advocate for payment reconsideration on denied claims.
- Follow the appropriate payor procedures for initiating reviews, reconsiderations and/or appeals.
- Follow-up with the payors to assure our requests are responded to within established/contracted timeframes.
- Utilize EPIC based functionality to document root causes, reflect current status within the appeals process to assure our internal customers know at a glance the current status of cases.
- Demonstrates skill in the proficient use of PC and UVA software systems to ensure that all
- pre-certification/pre-authorization or appeal information is entered into required computer systems in an accurate and timely manner.
- On-line data entry of certification/authorizations and denials/appeals are communicated to HSF, PFS and other Access staff and departments daily. Proficiency in the use of PC and required UVA software systems is appropriately demonstrated. Accuracy and Quality of pre-certification/pre-authorization documents are maintained for organized retrieval of patient records. Specific support functions are handled in an organized and timely fashion.
- Analyzes information required to complete pre-certifications and/or authorizations or appeals with insurance carriers, service area contacts and workman’s compensation carriers. Accurate and pertinent clinical data and demographics is compiled and communicated to the patients’ insurance company in a timely and organized fashion. Using independent judgment, employee determines if he/she has sufficient information to meet criteria for inpatient admissions and outpatient diagnostic tests prior to communication to carrier. Pre-certification/authorization services are understood and integrated in accordance with Health System and departmental policies and procedures by working collaboratively with designated contacts in service areas. Knowledge of insurance company criteria for inpatient admission and outpatient diagnostic testing is current. Admission procedures or appeals are communicated to insurance carriers via telephonic/fax/on-line review in an organized and timely fashion. Timely follow-up with insurance carriers is performed to obtain certification/authorization documentation for inpatient and outpatient services.
- Demonstrates the skills of effective communication, decision-making and organization to ensure efficient job performance and job success.
- Daily work is accomplished with minimal direct supervision. Work priorities are set in order to accomplish task/goals. Confidential matters are handled appropriately. Familiarity with current ICD-10 and CPT codes is demonstrated. Communication with Department billing staff is accomplished in a timely manner to ensure accurate pre-certification/authorization information is aligned with accurate billing of services. Ability to train staff and to act as a resource to other staff is demonstrated at all relevant times. Comprehension of insurance data, benefits, in/out of network issues, notification requirements, pre-determination services, and medical diagnosis is consistently demonstrated in order to ensure that all pre-certifications/authorizations are completed prior to the date of service. Sound judgment is consistently demonstrated as to when to involve physician or other health care professionals in the pre-certification/authorization or denial process.
- Demonstrates ability to adhere to policies and procedures. Compliance with program requirements and quality assurance is monitored consistently. Records are maintained, data is compiled and reports are prepared as requested by Management. Trends occurring in service areas are examined and communicated in a clear and concise manner for timely process improvements. Denial rates, set by Medical Center and HSF, are met in a timely fashion.
- In addition to the above job responsibilities, other duties may be assigned.
Position Compensation Range: $31.98 - $51.17 Hourly
MINIMUM REQUIREMENTS
Education: Graduate of an accredited nursing program required.
Experience: Five years relevant experience, one year of which should be in either in a hospital or ambulatory clinic environment dealing with payors in a Utilization/Case Management/Pre-Arrival role where prior authorizations, prior certifications, or appeals of denials for the same were pursued. Relevant experience on the payor side will also be considered.
Licensure: Licensed to practice as a Registered Nurse in the Commonwealth of Virginia
PHYSICAL DEMANDS
Job requires standing for prolonged periods, frequently bending/stooping, reaching (overhead, extensive, and repetitive); Repetitive motion: computer keyboard. Proficient communicative, auditory and visual skills; Attention to detail and ability to write legibly; Ability to lift/push/pull 50 - 100lbs. May be exposed to noise, radiation, radioactive materials, blood/body fluids and infectious disease.
The University of Virginia, including the UVA Health System which represents the UVA Medical Center, Schools of Medicine and Nursing, UVA Physician’s Group and the Claude Moore Health Sciences Library, are fundamentally committed to the diversity of our faculty and staff. We believe diversity is excellence expressing itself through every person's perspectives and lived experiences. We are equal opportunity and affirmative action employers. All qualified applicants will receive consideration for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex, pregnancy, sexual orientation, veteran or military status, and family medical or genetic information.
