RC Pre-Authorization Clinician

About the role

Working Location: THOP Memorial Campus. Spanish Bilingual Required.

The Revenue Cycle Management Clinician for the Pre-Authorization Solution is responsible for all clinical pre-authorization activities associated with patients financially cleared through the Patient Access Support Unit (PASU) and/or the Center for Patient Access Services (CPAS), and coordinating with ordering physicians and/or facility staff to secure the necessary prior payment authorization utilizing applicable payer criteria.

Responsibilities

• Performs pre-service authorization reviews to obtain payment authorization for both inpatient and outpatient services.
• Succinctly abstracts fact based clinical information to support pre-authorization utilizing applicable nationally recognized and payer-specific criteria; communicates timely the clinical information supporting the medical necessity of an ordered test/treatment/procedure/surgery as applicable to the patient's health plan and documents the outcome of the task.
• Performs the following activities to support the effective operation of the organization's quality management system (minimum of 2.5% of time): participation in quality control audit process; participation in department projects and activities to improve overall Conifer and client scorecard metrics; provides feedback regarding improvement opportunities for workflow &/or procedures; and contributes to successful implementation of all the above.
• Demonstrates proficiency in the use of multiple electronic tools required by both Conifer and its clients.
• Collaborate with and engage internal and external customers, such as facility patient access and physician offices, in opportunities for prevention of future disputes; identifies potential process gaps and recommends sound solutions to CAS leadership.
• Other duties as assigned.

Qualifications

• Ability to work independently and self-regulate in compliance with deadlines.
• Proficiency in the application of applicable nationally and payer authorization criteria.
• Possesses excellent customer service skills that include written and verbal communication.
• Minimum Intermediate Microsoft Office (Excel and Word) skill.
• Ability to critically think, problem solve and make independent decisions.
• Ability to interact intelligently and professionally with other clinical and non-clinical partners.
• Ability to prioritize and manage multiple tasks with efficiency.
• Advanced conflict resolution skills.
• Ability to communicate effectively at all levels.
• Ability to conduct research regarding payer pre-authorization guidelines and applicable regulatory processes related to the pre-authorization process.

Requirements

• Must possess a valid nursing license (Registered or Practical/Vocational). LPN or RN PREFERRED.
• Minimum of 3-5 years as a pre-authorization or utilization review nurse in a payer or acute care setting; preferably medical-surgical or critical care/ED.
• Current, valid RN/LPN/LVN licensure.
• Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR, CPUM, or CPHM) or Certified Case Manager (CCM) preferred.
• Ability to lift 15-20lbs.
• Ability to travel approximately 10% of the time; either to client &/or Conifer office sites.
• Ability to sit and work at a computer for a prolonged period of time conducting pre-service medical necessity reviews.
• Characteristic of typical Call Center environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.
• Interaction with staff at client facilities such as and not limited to Patient Access, Case management, physicians and/or their office staff is a requirement.
• May require travel – approximately 10%.