Pre-Authorization Coordinator- Orthopedic Clinic

About the Role

Responsible for utilization of clinical and financial resources by ensuring appropriate clinical level of care, ensuring appropriate documentation demonstrating medical necessity, and complying with organizational standards. Performs and submits clinical information to external payers to secure proper authorization and ensures prompt notification of any denials to the appropriate Care Coordinator, Denials/Appeals Coordinator, Team Leader, and/or Director. Performs all job duties for the age population served, as defined in the department's scope of service.

Responsibilities

• Coordinates utilization of clinical and financial resources
  • Prioritizes data collection based on the patient's immediate condition or needs according to procedure/surgery prior to booking surgery.
  • Ensures physician documentation is identified, accurate, and complete according to the regulations/policies of individual payers for procedure/surgery scheduled for each assigned patient.
  • Communicates with admitting physician for each patient to ensure proper documentation is complete prior to scheduled admission.
  • Identifies accurate payer information for each assigned patient.
  • Communicates and collaborates with the admission/precertification department to ensure appropriate payer precertification is completed for level of care status.
  • Performs admission review on all assigned inpatients and observation patients within one business day of admission for appropriateness of admission and level of care based on medical necessity utilizing InterQual criteria.
  • Refers appropriate cases to physician advisor or designee, communicating via email and/or telephonically.
  • Communicates with admitting physician as needed to ensure the correct admit level of care status.
  • Performs concurrent review on all assigned patients for appropriateness of level of care and continued stay based on medical necessity utilizing InterQual criteria as required by external payers.
  • Contacts physician and/or Care Coordinator for additional information regarding cases not meeting medical necessity criteria for admission and continued stay reviews.
  • Identifies and refers problem cases to appropriate Care Coordinator and/or supervisor.
  • Maximizes reimbursement by:
    • Communicating pertinent clinical information to payers.
    • Helping to ensure that physician documentation supports current clinical level of care.
    • Communicating and collaborating with Intake Nurse/Care Coordinator to assist with appropriate interventions to avoid denial of payment.
    • Assisting in arranging peer-to-peer conferences to avoid denial of payment.
    • Assisting in denials/appeals processes.
  • Identifies and communicates to the Care Coordinator opportunities for more efficient resource utilization.
  • Communicates and collaborates with the Pre-Authorization Coordinator for:
    • Cases that are not meeting medical necessity criteria for admission and continued stay reviews.
    • Cases that require peer-to-peer conferences.
    • Cases that have been issued denials and/or rejections.
  • Collaborates with the Care Coordinator in the development and implementation of the plan of care.
  • Documents in Allscripts specific patient information received regarding level of care, authorizations, and approved/denied days.
  • Communicates with payers regarding discharges by sending discharge notifications as appropriate.
  • Closes out each case once date of service authorization is complete.
  • Communicates with insurance specialist to ensure all authorizations are timely and complete.
• Participates in quality improvement activities
  • Reports sentinel events and quality of care issues to the Director of Case Management.
  • Collects and tracks data (denials, avoidable days, etc.) as determined by Supervisor and/or Director.
  • Participates in performance improvement activities as needed.
• Performs all other duties as assigned.

Requirements

• Experience
  • Required: 2 years of nursing experience.
  • Preferred: 2 years of clinical experience in case management.
• Education
  • Required: High School Diploma or GED.
• Special Skills or Knowledge
  • Required: Knowledge of ICD-9/10 coding and InterQual/MCG Criteria.
  • Ability to organize and prioritize work for optimal results.
  • Excellent analytical and problem-solving skills.

Additional Requirements

HIPAA & Safety

• Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to the job position, including but not limited to medical records, patient demographics, lab and radiology results, and patient financial information.
• Maintains knowledge of and adherence to all applicable safety practices appropriate to the job position, including incident reporting, PPE, exposure control plans, and hand washing.