Analyst

• Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
• Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual® or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits. Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual® 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 and follow documented processes for supporting the clinical appellate process.
• Adheres to the department standards for productivity and quality goals. Ensuring accounts assigned are worked in a timely manner based on the payor guidelines.
• Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual®, 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, denials management, etc.
• Additional responsibilities:
• 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.

Nurse Quality Analyst

Salary

Job Level

About the role

Requirements

Senior Patient Accounting Specialist

Patient Account Representative - Remote

Patient Account Representative

Assistant Manager, Appeals

Nurse Case Manager – Telephonic