Rn - Reviewer Contract Compliance, Mdiv, Ft Days, Mss: Corp - Mgd Care Rev Optim

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Summary:
Completes appeal documents based on medical necessity and appropriateness of services in response to denials and underpayments received from managed care plans.

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Detailed responsibilities:

• Reviews documentation from medical chart and applies clinical guidelines, regulations and/or payor contract terms to support medical necessity and appropriateness of services rendered. Formulates written document with findings to be used to assist with overturning denials.
• Prepares documents on unresolved cases and participates in meetings with clinical personnel from managed care companies to address cases.
• Assists with questions related to denials or underpayments concerning readmissions, coding, accuracy of charges, and/or duplication of services.
• Reviews and takes action on denials received from managed care payors while patient is still inhouse. Communicates directly with designees from managed care payors and/or internal departments to provide additional information to be evaluated to overturn denial.

Competencies and skills:
Essential:

• STANDARDS OF BEHAVIOR: Acts in a manner that supports the standards of communication, respect, privacy, and teamwork by demonstrating a commitment to professional and ethical conduct.
• EFFECTIVE COMMUNICATION: Communicates effectively with various audiences using the most appropriate method for the situation.
• DEVELOPING RELATIONSHIPS: Builds positive and productive business relationships with individuals and groups.
• ACCOUNTABILITY: Accepts ownership of job roles and specific assignments/goals; works independently, takes responsibility for own actions; admits mistakes and judgment errors; and accepts constructive feedback. Connects personal work results to the accomplishment of team and organizational goals.
• CUSTOMER SERVICE: Demonstrates commitment to service excellence by promptly addressing internal/external customer issues/requests, resolving concerns while maintaining a professional image and behavior to build and enhance the patient/family/customer experience.
• ANALYSIS AND DECISION MAKING: Uses decision making processes and tools to analyze situations and make effective decisions.
• CLINICAL POLICIES AND STANDARDS: Applies knowledge of clinical standards, policies, and procedures relevant to function and organization.
• TEAM WORK: Contributes to fullest potential to achieve team goals.
• RESPONDING TO CHANGE: Accepts change and adapts in a positive and productive manner; handles unexpected situations and changes in direction calmly and with confidence. Views new assignments and job responsibilities as an opportunity for growth.

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Education:
Essential:

• Accredited Program

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Education specialization:
Essential:

• Nursing

Credentials:
Essential:

• Registered Nurse License

Education equivalent experience:
Essential:

• •

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Other information:
Complexity of Work: Requires effective critical thinking skills, effective communication skills and decisive judgement. Must be able to make decisions and take appropriate action with minimal supervision. Requires knowledge with ability to apply Interqual, MCG Guidelines and/or state and federal regulations and statutes related to evaluating necessity of medical services. Working knowledge of managed care and managed care contract terminology. Intermediate level knowledge of Microsoft Word and basic level knowledge of Microsoft Excel.
Required Work Experience: 3 years clinical nursing experience in a hospital setting or clinical area of insurance company. Demonstrated ability to analyze and apply clinical criteria to decision making required.

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Working conditions:
Essential:

• Keyboard Entry ; ; ; 80.00%
• Repetitive Movement Hand/Arm ; ; ; 80.00%
• Distinguish Color ; ; ; 80.00%
• Depth Perception ; ; ; 80.00%
• Hearing Acuity ; ; ; 80.00%
• Seeing - Near ; ; ; 80.00%
• Sitting ; ; ; 80.00%
• Walking ; ; ; 80.00%
• Audible Speech ; ; ; 80.00%
• Standing ; ; ; 80.00%
• Computer Monitor ; ; ; 80.00%
• Seeing - Far ; ; ; 80.00%

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