As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
The Revenue Cycle Clinician for the Appellate Solution is responsible for:
a) Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review
b) Preparing and documenting appeal based on industry accepted criteria.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
Performs retrospective (post â��discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQualâ® criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process.
Demonstrates proficiency in use of medical necessity criteria sets, currently InterQualâ®, as evidenced by Inter-rater reliability studies and other QA audits.
Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, MedAssets (formerly IMaCs), eCARE, Authorization log, InterQualâ®, VI, HPF, as well as competency in Microsoft Office.
Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc.
Serves as a resource to non-clinical personnel.
Provides CRC leadership with sound solutions related to process improvement
Assist in development of policy and procedures as business needs dictate.
Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Demonstrates proficiency in the application of medical necessity criteria, currently InterQualâ®
Possesses excellent written, verbal and professional letter writing skills
Critical thinker, able to make decisions regarding medical necessity independently
Ability to interact intelligently and professionally with other clinical and non-clinical partners
Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms
Ability to multi-task
Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.
Ability to conduct research regarding off-label use of medications
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience required to perform the job.
Must possess a valid nursing license (Registered or Practical/Vocational)
Minimum of 5 years recent acute care experience with the last 2 years in a facility environment
Medical-surgical/critical care experience preferred
Minimum of 2 years UR/Case Management experience within the last 2 years
Managed care payor experience a plus either in Utilization Review, Case Management or Appeals
Patient Accounting experience a plus
Previous classroom led instruction on InterQualâ® products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred
CERTIFICATES, LICENSES, REGISTRATIONS
Current, valid RN/LPN/LVN licensure
Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred
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.
Ability to lift 15-20lbs
Ability to travel approximately 10% of the time; either to facility sites, National Insurance Center (NIC) sites, Headquarters or other designated sites
Ability to sit and work at a computer for a prolonged period of time conducting medical necessity reviews
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.
Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.
May require travel â�� approximately 10%
Interaction with facility Case Management, Physician Advisor is a requirement.
Job: Conifer Health Solutions
Primary Location: Marlborough, Massachusetts
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.