Description SHIFT: Work From Home SCHEDULE: Full-time Work From Home (WFH) potential Job Summary – The Prebill Denials Nurse will review post discharge, prebill accounts that do not have an authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require clinical expertise.
Communicates with third party payors to resolve discrepancies prior to billing.
Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures.
Escalate medical review request and/or denial activities to management as needed.
Duties (included but not limited to):
- Work post discharge, prebill accounts efficiently and effectively on a daily basis to resolve accounts with “no auth numbers, ALOS vs.
authorized days or other discrepancies
- Evaluates clinical documentation on multiple patient accounts and escalates issues through the established channels
- Perform accurate and timely documentation of all review activities based on policy and procedure
- Demonstrates a working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information.
Escalates variations timely.
- Work assigned accounts in eRequest to resolve outstanding issues
- Report insurance denial trends identified during daily operational assignments
- Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed
- Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives.
- Assess CPT code(s) for outpatient accounts that require authorization when accounts have not been coded
- Other duties as assigned Qualifications EDUCATION Registered Nursing degree and current licensure EXPERIENCE Healthcare experience in an acute care hospital.
Utilization Review, appeals, denials, managed care contracting, experienced preferred CERTIFICATE/LICENSE – RN with current state licensure KNOWLEDGE, SKILLS & ABILITIES
- Communication - communicates clearly and concisely, verbally and in writing.
This includes utilizing proper punctuation, correct spelling and the ability to transcribe accurately.
- Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
- Interpersonal skills - able to work effectively with other employees, patients and external parties
- PC skills - demonstrates proficiency in Microsoft Office applications and others as required
- Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems
- Clinical skills – ability to read/ interpret medical record documentation and present the clinical data obtained in an organized, concise dialogue to the payor in order to obtain auth and/or resolve other issues.
- Basic skills - demonstrates ability to organize, perform and track multiple tasks accurately in short timeframes, have ability to work quickly and accurately in a fast-paced environment while managing multiple demands, ability to work both independently and collaboratively as a team player, adaptability, analytical and problem solving ability and attention to detail and able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately.
PHYSICAL DEMANDS/WORKING CONDITIONS Requires prolonged sitting/standing, some bending, stooping, walking and stretching.
Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment.
Requires normal range of hearing and eyesight to record, prepare and communicate appropriate reports or other information.
Requires lifting papers/boxes and pushing/pulling up to 25 pounds occasionally.
Work is performed in an office environment or hospital setting.
Work may be stressful at times.
Contact may involve dealing with angry or upset people.
Staff must remain flexible and available to provide staffing assistance for any/all disaster or emergency situations.