This site uses cookies. To find out more, see our Cookies Policy

Case Management Quality Review Nurse in Nashville at Parallon

Date Posted: 3/18/2019

Job Snapshot

Job Description

Parallon believes that organizations that continuously learn and improve will thrive. That’s why after more than a decade we remain dedicated to helping hospitals and hospital systems operate knowledgeably, intelligently, effectively and efficiently in the rapidly evolving healthcare marketplace, today and in the future. As one of the healthcare industry’s leading providers of business and operational services, Parallon is uniquely equipped to provide a broad spectrum of customized revenue cycle services.


We are a wholly owned subsidiary of HCA, a Fortune 100 company with more than 200,000 employees and one of the nation's leading providers of healthcare services, operating over 170 locally managed hospitals and over 100 freestanding surgery centers in 20 states and the United Kingdom. HCA has been named one of the world's most ethical companies for eight years in a row. At HCA, we are driven by a single goal: the care and improvement of human life.


*Located in Nashville at Parallon Corporate*
 
Job Summary



The Case Management Quality Review 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.
 
Duties:

  • 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 channels
  • 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.
  • Assess CPT code(s) for outpatient accounts that require authorization when accounts have not been coded
  • Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous
  • Communicates effectively and professionally with physicians, hospital staff, and outside agencies



Job Requirements

Education

  • Registered Nursing degree and current licensure



 
Experience

  • Healthcare experience in an acute care hospital. Utilization Review, appeals, denials, managed care contracting, experienced preferred



 
Benefits of working at Parallon
Our benefits package allows you to select the options that best meet the needs of you and your family. Benefits include 401k with a company match, paid time off, medical, dental, vision, flex spending for both health and day care, life insurance, disability, tuition reimbursement and student loan repayment, employee discount program, employee stock purchase program.
 
We are an equal opportunity employer and we value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.
 
#ParallonBCOM