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Employment Type:

Full time

Shift:

Day Shift

Description:

Position Purpose

The Clinical Pre-Service Nurse Coordinator is directly responsible for reviewing pre/post service initial denials, securing escalated insurance authorizations, handling escalated medical necessity reviews and coordinating with Patient Access, Mid-Revenue Cycle and Patient Business Service (PBS) to identify opportunities for revenue optimization. Works closely with Physician Providers to assure that the proposed intensity of service is in alignment with the severity of illness and accurately documented to support level of care determinations and required authorizations. Investigates denials and root causes and tracks and reports trends to remediate issues and assist with internal process improvement. Leverages clinical knowledge and standard procedures to ensure timely attention to denials as requested by PBS and assists in the research and application of regulatory policies to support administrative appeals. This role will be under the Pre-Service Insurance Verification team with collaboration opportunities with Case Management.

What you will do

+ Communicate pertinent clinical information to Physicians, Medical Directors, and CFO regarding evaluation of medical appropriateness and/or payer determinations

+ Discuss complex medical necessity cases in all aspects of prior authorization work with physician

+ Act as a resource to other departments leveraging clinical expertise as it relates to the preauthorization process

+ Coordinate denial management processes (i.e., Initial Denials such as administrative/technical accounts, and Operational Write-offs) focusing upon process improvement and resolution follow-up

+ Collaborate with intra-department and PBS teams on accurate documentation and reporting of key performance indicators and participate in development of action plans to ensure goals are met

Minimum Qualifications

+ Registered Nurse (RN) or Licensed Vocational Nurse/ Licensed Practical Nurse (LVN/LPN) and/or a Nurse Compact License NLC

+ Two (2) years of nursing experience and two (2) years of pre-certification/prior approval clinical denial unit management experience

+ Certification and/or membership in AAPC, AHIMA, HFMA, AAHAM, NAHAM strongly preferred

+ Knowledge of patient access, revenue cycle and denial management functions; technical and clinical denials areas, such as medical necessity, eligibility issues, no authorization

+ Medical record coding experience (ICD-9, CPT, HCPCS) highly desirable

+ Experience in case management / utilization management and managed care contracts

+ Knowledge of insurance and governmental programs, regulations, and billing processes (e.g., Medicare, Medicaid, managed care contracts and coordination of benefits) is required

Position Highlights and Benefits

+ Full time 40hrs M-F days

+ Excellent benefits - starting day 1!

Ministry/Facility Information

Saint Francis Hospital is committed to exceeding the expectations of our patients and families by providing world-class service in a progressive, people-centered, compassionate health care environment. We are licensed for 617 beds and 65 bassinets, are a major teaching hospital and the largest Catholic hospital in New England.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran