Prebill Denials RN in Houston at Parallon

Date Posted: 8/10/2019

Job Snapshot

Job Description



GENERAL SUMMARY OF DUTIES The Prebill Denial Nurse will review post discharge, prebill accounts that do not have an authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require  clinical expertise. Communicates with third party payors to resolve discrepancies prior to billing. Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures. Escalate medical review request and/or denial activities to management as needed  


 
SUPERVISOR – SSC Denial Director  

 
SUPERVISES – NA  

 
Functional areas:
  • Obtain authorizations for post discharge, prebill accounts  

  • Perform re-certification for additional days on post discharge, prebill accounts  

  • eRequest queues as determined during program implementation  


 
OPERATIONAL DUTIES INCLUDE BUT ARE NOT LIMITED TO:  

  • Work post discharge, prebill accounts efficiently and effectively on a daily basis to resolve accounts with “no auth numbers, ALOS vs. authorized days or other discrepancies  

  • Evaluates clinical documentation on multiple patient accounts and escalates issues through the established chain of command  

  • Perform accurate and timely documentation of all review activities based on policy and procedure  

  • Demonstrates a working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information.  Escalates variations timely.  

  • Work assigned accounts in eRequest to resolve outstanding issues  

  • Report insurance denial trends identified during daily operational assignments  

  • Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed  

  • Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives.  

  • Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous  

  • Communicates effectively and professionally with physicians, hospital staff, and outside agencies  

  • Adhere to all policies and procedures, including, attendance, phone and internet usage, break utilization, etc.  

  • Participate in education and training as needed  

  • Establish and maintain relationships with all customers  

  • Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous  

  • Adheres to established policy and procedure and standards of care;  escalates issues through the established Chain of Command timely  

  • Demonstrates commitment to teamwork and cooperation    

  • Practice and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement”
  • Other duties as assigned



 


Job Requirements

KNOWLEDGE, SKILLS & ABILITIES
 
  • Communication – ability to communicate effectively in oral, written and electronic formats  

  • Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations  

  • Interpersonal skills – ability to establish and maintain collaborative and effective working relationships  

  • PC skills – demonstrates proficiency in Microsoft Office applications and others as required  

  • Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems  

  • Basic skills – demonstrates an ability to organize, perform and track multiple tasks accurately in short timeframes of one continuously scheduled shift or less and have ability to work quickly and accurately in a fast-paced environment while managing multiple demands  

  • Clinical skills – ability to read/ interpret medical record documentation and present the clinical data obtained in an organized, concise dialogue to the payor in order to obtain auth and/or resolve other issues.


EDUCATION
 
  • Associate’s Degree or higher preferred


EXPERIENCE  
  • Utilization Review, appeals, denials, managed care contracting, experienced preferred

   
CERTIFICATE/LICENSE – RN or LPN/LVN with current state licensure  
PHYSICAL DEMANDS/WORKING CONDITIONS - Requires prolonged sitting, some bending,stooping and stretching. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment. Requires normal range of hearing and eyesight to record, prepare and communicate appropriate reports. Requires lifting papers or boxes up to 25 pounds occasionally. Work is performed in an office environment. Work may be stressful at times. Contact may involve dealing with angry or upset people. Staff must remain flexible and available to provide staffing assistance for any/all disaster or emergency situations.