Job Description

ECU Health

About ECU Health Medical Center
ECU Health Medical Center, one of four academic medical centers in North Carolina, is the 974-bed flagship hospital for ECU Health and serves as the primary teaching hospital for The Brody School of Medicine at East Carolina University. ECU Health Medical Center has achieved Magnet® designation twice and provides acute and intermediate care, rehabilitation and outpatient health services to a 29-county region that is home to more than 1.4 million people.
Position Summary

• Responsible for the timely review of denied claims from all payers related to medical necessity, appropriate setting/status determination, authorizations and appropriate length of stay.
• Ensure all denied claims are accurately worked and appealed to obtain maximum reimbursement and minimize recoupment.
• Combine clinical, business and regulatory knowledge and skills to reduce financial risk and exposure caused by concurrent and retrospective denial of payment for rendered services.
• Utilize MCG guidelines, Medicare's 2-midnight rule, and any other payer specific requirement for inpatient, along with the appropriate payer medical policy or NCD/LCD for outpatient services.

Responsibilities

• Reviews Medical Record and determines whether each case should be appealed, downgraded, or referred to physician advisors (PAs).
• Downgrading would occur if PA indicated in notes or no clinical justification noted in medical record.
• Appeals would be written if related to deaths, AMAs, auths due to payer error or when already received.
• Appeal referral when a physician is required to support medical necessity.
• A medical record review may include investigating a patient's medical and treatment history or obtaining external medical records necessary to support the hospital medical record.

Minimum Requirements

• Bachelor of Science in Nursing.
• 5 years of related work experience within Case Management, Utilization Review, or Clinical Documentation Improvement.
• In place of a Bachelor's in Nursing, an Associate Degree in Nursing (RN) is acceptable with an accompanying 10 years experience in Case Management, Utilization Review, or Clinical Documentation Improvement.

General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.
Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.
We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant's qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.