Prebill Denials LPN in Houston at Parallon

Date Posted: 8/10/2019

Job Snapshot

Job Description

Job Summary – The Prebill Denials 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 – Prebill Denials Director/Manager

Supervises – not applicable

Duties (included but 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 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
• Adhere to time and attendance policies
• Adhere to all policies and procedures, including, 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

Communication - communicates clearly and concisely, verbally and in writing. This includes utilizing proper punctuation, correct spelling and the ability to transcribe accurately.
Customer orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
Interpersonal skills - able to work effectively with other employees, patients and external parties
PC skills - demonstrates proficiency in Microsoft Office applications and others as required
Policies & Procedures - demonstrates knowledge and understanding of organizational policies, procedures and systems
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.
Basic skills - demonstrates ability to organize, perform and track multiple tasks accurately in short timeframes, have ability to work quickly and accurately in a fast-paced environment while managing multiple demands, ability to work both independently and collaboratively as a team player, adaptability, analytical and problem solving ability and attention to detail and able to perform basic mathematical calculations, balance and reconcile figures, punctuate properly, spell correctly and transcribe accurately.

LPN licensure

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

LPN with current state licensure