The Nevill Group provides expertise, and seeks it within our employees. We also seek a genuine level of care for patient outcomes as well as the client’s financial success.
The Utilization Review Nurse is responsible for the development, implementation, coordination, and follow-up of projects. This includes the validation, assimilation, and integration of information derived from projects, focus studies, in network and out of network pre-certification, inpatient concurrent review and retrospective chart review. Performs related duties as assigned. Performs duties and responsibilities in a manner consistent with our mission, values, and Mercy Service Standards.
Coordinates and performs precertification, out of network precertification, inpatient concurrent review, retrospective review, reconsiderations and appeals. Performs each review process following the appropriate policy & procedure and within standard time frames.
Collaborates with physicians and staff to provide medical management education and follow-up for precertifications, inpatient concurrent review, retrospective review and appeals. Collaborates with providers, as indicated, to provide them with medical management information.
Performs telephone management with professional telephone etiquette when communicating with all parties.
Collects and researches medical records and other forms of information to make effective and accurate non-medical decisions concerning all medical management review processes.
Composes, types and mail standard letters of denials to health plan members, providers, and health plans member services referencing specific medical criteria utilized in the determination.
Collaborates with physicians, facilities, health plan member services and claims staff as needed to obtain information regarding claim denials, their status, and actions taken that may affect their outcome.
Develops and maintains a system for collecting, researching and coordinating information between TNG Management, Client Care Management Medical Director(s), providers and outside agencies involving denials and appeals, and for recording and retrieval of that information.
Implements and coordinates special medical management projects as directed. Maintains health plan benefit materials in reference manuals. Acts as a liaison to Provider Relations Department for contracted health plans.
Maintains reports relating to the implementation, coordination, and follow-up of medical management review processes and special projects. Develops and maintains reporting tools and formats for denials and appeals, special projects and other departmental activities as requested.
Screens and refers appropriate health plan members for full continuum case management, disease management, Nurse on Call or other care management strategies as applicable.
Interacts with Data Management and appropriate Supervisor to provide system maintenance to the Referral and Case Management applications.
Refers cases that do not meet medical criteria for precertification, inpatient concurrent review, and retrospective review to a TNG Care Medical Director or Physician Advisor.
Compiles statistical information related to all medical management review processes as requested.
Performs retrospective chart review as indicated.
The Clinical Appeals Specialist is responsible for managing client medical denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Where warranted, the Clinical Appeals Specialist will write sound, compelling factual arguments for Audit team review to determine if an appeal is warranted. The Clinical Appeals Specialist will also attend Administrative Law Judge hearings, handle audit-related correspondence and other administrative duties as required.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Core duties and responsibilities include the following:
- Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required.
- Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments, where an appeal is warranted.
- Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments, for an Administrative Law Judge hearing and participate in hearings by providing testimony, as necessary.
- Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
- Prepare feedback to clients and participate in client meetings.
- Discuss documentation-related and level of care decisions with clients, independently, as required.
- Proficiently read and understand abstract information from handwritten patient medical records.
- Ensure compliance with HIPAA regulations, to include confidentiality, as required.
- Other duties as assigned.
No direct supervisory responsibilities.
- Analytical – Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data; Designs work flows and procedures.
- Problem Solving – Identifies and resolves problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Works well in group problem solving situations; Uses reason even when dealing with emotional topics.
- Oral Communication – Speaks clearly and persuasively in positive or negative situations; Listens and gets clarification; Responds well to questions; Demonstrates group presentation skills; Participates in meetings.
- Written Communication – Writes clearly and informatively; Edits work for spelling and grammar; Varies writing style to meet needs; Presents numerical data effectively; Able to read and interpret written information.
- Quality – Demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
- Character – Demonstrates unquestionable integrity in every aspect of work and dealing with others; Consistently models desired behaviors and values established by the company; Respects diversity of perspective in discussions and demonstrates an inclusive style; Demonstrates concerns for job safety for self and others.
- Organizational Support – Follows policies and procedures; Completes administrative tasks correctly and on time; Supports organization’s goals and values; Supports affirmative action and respects diversity.
- Dependability – Follows instructions, responds to management direction; Takes responsibility for own actions; Keeps commitments; Commits to long hours of work when necessary to reach goals; Completes tasks on time or notifies appropriate person with an alternate plan.
- Administrative Management – Continuously manages administrative functions to ensure quality and timeliness, manages accurate and timely activity and performance reports.
Bachelor’s Degree in Nursing or an equivalent degree in a related discipline required, as well as a current state-issued RN license. Knowledge in areas such as InterQual Level of Care Criteria and Milliman & Robertson Criteria as well as knowledge of third party payer regulations related to utilization and quality review is also preferred.
- Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse in an acute care setting. In addition, having at least two to three years experience in case management, discharge planning, and/or utilization review is preferred.
- Knowledge of regulatory and payer requirements for reimbursement and reason(s) for denials by auditors.
- Ability to critically evaluate and make decisions about whether appeals should be made based on reviews of patient medical records.
- Skill in writing convincing appeals arguments that are sound and supported by evidence that is related to patients’ specific clinical attributes.
- Ability to use pre-existing criteria sets and/or clinical evidence from an existing library of clinical references and/or regulatory arguments to support one’s own clinical appeals arguments.
- Ability to search for supporting clinical evidence to support appeal arguments when there are not existing resources available.
- Demonstrated ability to prepare arguments for an Administrative Law Judge Hearing and participate in a hearing.
- Ability to proficiently read, understand, and abstract information from handwritten patient medical records are essential prerequisites.
- Ability to work in a home-based environment and to work independently as an individual contributor and adapt quickly to changing priorities.
- Maintains confidentiality of patient data and medical records in compliance with HIPAA regulations.
- Ability to read, evaluate, and abstract important information from handwritten patient medical records.
- Excellent oral and technical writing and typing skills.
- Demonstrates flexibility with a willingness to learn and adapt to changes in regulations and task-related priorities.
- Ability to successfully work independently and to adapt quickly to changing priorities and regulations.
- Excellent oral and technical writing skills and the ability to maintain confidentiality according to HIPAA regulations is required.
- Ability to travel as required.
- Other duties as assigned.
Principal Duties and Responsibilities
Acute Inpatient/Care Management Functions
- Reviews medical records of patients identified by care managers or as requested by the healthcare team in order to:
- Assist with level of care and length of stay management
- Assist with the denial management process
- Review and make suggestions related to resource and service management
- Assist staff with the clinical review of patients
- Determine if professionally recognized standards of quality care are met
- Provides feedback to attending and consulting physicians regarding level of care, length of stay, and quality issues.
- Seeks additional clinical information from the attending and consulting physicians.
- Recommends and requests additional, more complete, medical record documentation.
- Recommends next steps in coordination of care and evidence-based medicine indicators.
- Reviews cases that indicate a need for issuance of a hospital notice of non-coverage/important message from Medicare.
- Discusses the case with the attending physician and if additional clinical information is not available, discusses the process for issuance and appeal to the physician.
- Documents patient care reviews, decisions, and other pertinent information.
- Understands and uses InterQual and other appropriate criteria.
- Documents response to case management referrals.
- Supports Care Management in a data-driven approach.
- Notifies the care manager of any conflict of interest in reviewing a particular patient record.
- Assists with identifying a physician to review such record.
- Acts as a liaison with payers to facilitate approvals and prevent denials or carved out days when appropriate.
- Facilitates, mentors, and educates other physicians regarding payer requirements.
- Participates in review of long stay patients, in conjunction with the Care Management Leadership, Care Management Team and other members of the multidisciplinary team to facilitate the use of the most appropriate level of care.
- Participates in patient rounds with the Healthcare Team as indicated.
- Identifies patients who are appropriate for transfer to LTACH facilities and works with physicians to facilitate referrals as needed.
- Provides guidance to ED physicians and ED Care Management regarding status issues and alternatives to acute care when acute care is not warranted.
- Works with Care Management and an interdisciplinary team to ensure appropriate continuity of care and to reduce readmissions.
Physician Support and Education
- Provides education to physicians and other clinicians related to regulatory requirements, appropriate utilization, alternative levels of care, community resources, and end of life care.
- Works with physicians to facilitate referrals to the continuum of care.
- Assists physicians with end of life and hospice care consultations when appropriate.
- Provides education to physicians and other clinicians regarding inappropriate admissions to the ICU and creates action plans to address these patients.
Hospital Process Improvement
- Identifies quality, safety, patient satisfaction and efficiency issues leading to suboptimal care.
- Takes appropriate action to resolve.
- Promotes and educates healthcare team on a team approach to patient care.
- Promotes coordination, communication and collaboration among all team members.
- Supports the organization in quality improvement efforts requiring physician input and/or involvement.
Clinical Documentation Support
- Educates individual hospital staff physicians about ICD coding guidelines (e.g., co-morbid conditions, outpatient vs. inpatient) and clinical terminology to improve their understanding of severity, acuity, risk of mortality, and DRG assignments on their individual patient records.
- Educates specific medical staff departments (e.g., Internal Medicine, Surgery, Family Practice, etc) at departmental meetings regarding:
- Reasons why individual physicians should be concerned about correct disease reporting and the subsequent ICD code capture of severity, acuity, risk of mortality, and DRG assignment, such as: Physician performance profiling, Physician E&M payment and pay for performance.
- Appropriate hospital reimbursement and profiling for patient care.
- Ways to provide improved health record documentation that specifically affect ICD code assignment capture of severity, acuity, risk of mortality, and DRG assignment.
Medical Informatics Support
- Works with the EHR team to ensure the system appropriately supports the physician’s ability to provide best practice medicine by creating logical processes and providing the necessary order sets and practice guidelines.
- Participates in physician education and outreach efforts.
- Works in collaboration with the IT team to be sure all necessary physicians are trained and training is appropriate for the physicians.
- Participates as part of the physician advisory council to assist IT with clinical decisions for the EHR.
- Assists with order set development, review, and implementation to coordinate quality, efficiency, and utilization of the order sets.
Additional Job Functions
- Serves on the Utilization Management Team.
- Participates in the peer review process and makes suggestions on ways to improve this process.
- Assists with the evaluation of the hospital utilization management program.
- Maintains current knowledge of federal, state, and payer regulatory and contract requirements.
- Attends continuing education sessions pertaining to utilization and quality management.
- Additional functions as deemed appropriate and warranted.
- Graduate of an accredited medical school.
- Additional education in quality and utilization management through continuing medical education programs and self-study.
- Minimum of 5 years recent experience in clinical practice.
- Utilization management experience as a member of the UM oversight committee or past physician advisor experience preferred.
- Licensed physician
- Obtaining referrals and pre-authorizations as required for procedures.
- Checking eligibility and benefits verification for treatments, hospitalizations, and procedures.
- Reviewing patient bills for accuracy and completeness, and obtaining any missing information.
- Preparing, reviewing, and transmitting claims using billing software, including electronic and paper claim processing.
- Following up on unpaid claims within standard billing cycle timeframe.
- Checking each insurance payment for accuracy and compliance with contract discount.
- Calling insurance companies regarding any discrepancy in payments if necessary
- Identifying and billing secondary or tertiary insurances.
- Reviewing accounts for insurance of patient follow-up.
- Researching and appealing denied claims.
- Answering all patient or insurance telephone inquiries pertaining to assigned accounts.
- Setting up patient payment plans and work collection accounts.
- Updating billing software with rate changes.
- Updating cash spreadsheets, and running collection reports.
In addition to these general duties, we may request that you perform other duties that fit with your training and background experience or provide further training for new duties.
Education and Experience Required
The amount of education and experience we require will vary depending on the complexity of the job and need. A minimum work experience is often preferred, but everyone needs to begin somewhere. Don’t let a minimum number of years of job experience deter you if you feel you have been properly trained to fulfill all potential duties at a particular job.
- A high school diploma
- Knowledge of business and accounting processes usually obtained from an associate’s degree, with a degree in Business Administration, Accounting, or Health Care Administration preferred.
- A minimum of one to three years of experience in a medical office setting.
Knowledge, Skills, and Abilities
We will want to see you demonstrate knowledge, skills, and abilities in a number of areas. You will likely be asked about these in an interview, and we may ask what skills you’ve used in any previous jobs as a medical biller.
Proficiency in the following areas is preferred:
- Knowledge of insurance guidelines including HMO/PPO, Medicare, Medicaid, and other payer requirements and systems.
- Competent use of computer systems, software, and 10 key calculators.
- Familiarity with CPT and ICD-10 Coding.
- Effective communication abilities for phone contacts with insurance payers to resolve issues.
- Customer service skills for interacting with patients regarding medical claims and payments, including communicating with patients and family members of diverse ages and backgrounds.
- Ability to work well in a team environment. Being able to triage priorities, delegate tasks if needed, and handle conflict in a reasonable fashion.
- Problem-solving skills to research and resolve discrepancies, denials, appeals, collections. A calm manner and patience working with either patients or insurers during this process.
- Knowledge of accounting and bookkeeping procedures.
- Knowledge of medical terminology likely to be encountered in medical claims.
- Maintaining patient confidentiality as per the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
- Ability to multitask.
Interested in learning more about one of these positions? Let’s get the conversation started.
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