About the job XTN-37FF611 | CLINICAL SERVICES PROCESS ASSOCIATE
Functional overview
This should explain, in summary, the general responsibilities and the key tasks of the role. This should also include their purpose, relationships with customers, co-workers, and others, and the results expected of incumbent employees.
Duties and responsibilities
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Ø Provide health care utilization review services regarding admissions, observations, Discharge Wqs based on the payer types and review types. |
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Ø Review admissions and service requests within assigned unit for prospective, concurrent, and retrospective medical necessity and/or compliance with reimbursement policy criteria. |
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Ø Assist with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals. |
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Ø Notifies attending physician and other members of the health care team of inappropriate admissions, denials, end of authorized days, or other factors that have a reimbursement impact. |
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Ø Consults with attending physician when documentation in the medical record does not support admission or continued stay and seeks to ensure completeness of all clinical documentation. |
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Ø Functions as liaison between the Physician Advisor and the attending physician.. |
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Ø Documents denial information in electronic medical record system including attempts at resolution/overturning of the denial. |
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Ø Provides all payor communication to be scanned into the system for use in appeals. |
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Ø Application of MCG and InterQual guidelines for each case review to determine the status. |
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Ø Consults with medical and treatment staff regarding client diagnosis, medical justification, length of treatment, and case documentation. |
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Ø Participates in utilization and peer review meetings and projects. |
Minimum competencies
Should list down skills, knowledge and/or behaviour. Can include areas of expertise.
Minimum qualifications
Indicate required educational background. Previous work experiences needed or preferred. Any technical skills required.