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Support the authorization department through utilization of clinical knowledge with associated treatments. Provides analysis of medical records to determine medical necessity in the clinical record and provides feedback to the providers and clinical team. Navigates high dollar treatments and provides additional clinical support as well as potential patient contact.
MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. High school graduate or equivalent.
2. Current West Virginia licensure as a Licensed Practical Nurse (LPN).
EXPERIENCE:
1. Two (2) years of healthcare experience.
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Associate or advanced degree preferred
2. Current West Virginia licensure as a Registered Professional Nurse.
CORE JOB 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. Reviews the medical record for clinical documentation in relation to ordered treatment. Provides education to providers in relation to insurance policy of any variances.
2. Provides coordination of high dollar services that would include analyzing the medical record for medical necessity and provides authorizations. Acts as a point of contact for assigned services that will interact with the clinical leaders in the department.
3. Researches each request including reviewing medical policy to ensure each requests is processed with minimum delay and risk of denial.
4. Effectively communicates clinical information with payor to obtain authorization for appropriate level of care and procedure, and documents interactions in patient’s electronic medical record (EMR).
5. Provides prompt follow up with the Payor to ensure current authorization and accurate payment for the patient’s stay/treatment.
6. Provides prompt feedback regarding payor determination to Supervisor/Clinic, enabling them to evaluate/redirect the current patient plan of care in order to streamline the delivery of service.
7. Identifies pre-services denials by third party payor and notifies Supervisor/Clinic for immediate intervention.
8. Proactively communicates any change in payor information and follows up with payor to ensure services are authorized. Documents all changes and all payor information (i.e. DOS, Service (CPT/HCPC codes), LOC, Reference #, Authorization #, contact and phone number, and website used) appropriately.
9. Based on assigned area, communicates with patient to obtain any and all information needed, scheduling, Charge Capture, verify and obtain referrals and pre-authorizations both for services provided within the hospital system and outside facilities.
10. Communicates with the patient in regards to insurance information needed, the anticipated self-pay portion including co-payments/deductibles/co-insurance. Provides available denial information and appeal options to the patient.
11. Completes assigned appeals for retro-authorizations focusing on medical necessity. Utilizes the physician documentation when appropriate to support services rendered
12. Notifies financial counseling of all patients with a high out of pocket. Refers self-pay patients with limited or exhausted benefits to financial counselors and/or social worker to determine eligibility.
13. Researches and resolves denials and communicates findings to department and/or Clinical Denial teams.
14. Maintains confidentiality/HIPPA according to policy when interacting with patients, physicians, families, co-workers and the public regarding demographic/clinical/financial information.
15. Reviews medical records and applies information to payor policies or LCD/NCD. Notifies treatment team of missing documentation pre-service.
16. Maintains assigned Work Queues in a timely and effective manner.
17. Participates in on-going educational activities to develop, maintain and enhance professional expertise as determined by leadership.
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. Must be able to sit for extended periods of time.
2. Must have reading and comprehension ability.
3. Visual acuity must be within normal range.
4. Must be able to communicate effectively.
5. 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. Office type environment.
SKILLS AND ABILITIES:
1. Excellent oral and written communication skills.
2. Excellent customer service and telephone etiquette.
3. Must demonstrate the ability to use tact and diplomacy in dealing with others.
4. Knowledge of ICD9/CPT Coding or Medical Terminology.
5. Knowledge of third party reimbursement.
Additional Job Description:
Scheduled Weekly Hours:
40
Shift:
Varied (United States of America)
Exempt/Non-Exempt:
United States of America (Non-Exempt)
Company:
WVUH West Virginia University Hospitals
Cost Center:
403 WVUH Care Management
Address:
1 Medical Center DriveMorgantownWest Virginia
WVU Medicine is proud to be an Equal Opportunity employer. We value diversity among our workforce and invite applications from all qualified applicants regardless of race, ethnicity, culture, gender, sexual orientation, sexual identity, gender identity and expression, socioeconomic status, language, national origin, religious affiliation, spiritual practice, age, mental and physical ability/disability or Veteran status.
