What are the responsibilities and job description for the Precertification Nurse Reviewer - FT Exempt position at Wooster Community Hospital?
WOOSTER COMMUNITY HOSPITAL JOB DESCRIPTION
Precertification Nurse Reviewer
Main Functions:
The Precertification Nurse Reviewer utilizes clinical experience and medical guidelines in a collaborative approach to assure the seamless delivery of precertification services and optimal reimbursement for WCH. Determines medical necessity and appropriateness of requested inpatient and outpatient services through review of clinical information and application of the appropriate clinical criteria guidelines. Ensures all scheduled and non-scheduled services requiring prior authorization/precertification have the correct and appropriate authorizations prior to services being rendered.
Responsible To: System Director of Revenue Cycle
Must Have Requirements:
- LPN or RN possessing an active Ohio license
- Ability to self-direct and manage time effectively
- Ability and willingness to learn new systems and processes.
- Ability and willingness to adapt to changing organizational needs and priorities
- Must possess excellent verbal and written communication skills in dealing with internal and external customers
- Ability to work independently and problem solve complex, multifaceted situations
Preferred Attributes:
- Demonstrated experience in revenue cycle principles
- 2-3 years of Utilization Management experience in an acute care setting
- Strong familiarity with ICD diagnosis codes and CPT codes
- Knowledge of Medicare reimbursement/payment policies and payor specific criteria
- Proficiency in Microsoft Word and Excel _____________________________________________________________________________________ Position Expectations: All expectations are detailed below are considered ADA (American Disabilities Act) Essential.
- Follows appropriate service standards
- Provide clinical support to non-clinical precertification staff
- Identifies opportunities for improvement through daily work processes and communicates information to leadership
- Assess and review precertification requests for medical services requiring clinical review against payor adopted criteria
- Works closely with Physician Clinical Risk Advisor as it relates to potential non-authorized services
- Completion and tracking of all cases sent to nursing review
- Coordination with providers and office staff to facilitate peer to peer review along with tracking/trending of referred cases
- Coordinates with Physician Clinical Risk Advisor and leadership to communicate opportunities for improvement with provider offices as it relates to supporting documentation for requested outpatient services
- Review of scheduled surgeries to assure appropriate codes and appropriate status prior to initiation of precert process
- Identification & tracking of potential high-cost procedures
- As appropriate, validation of medical necessity (LCD/NCD review) of Medicare and NonMedicare cases to ensure clinical and financial clearance
- Communication with scheduling and/or ancillary department staff for clarification of diagnosis and/or tests/procedures
- Cross-trained in various precert functions as needed to assist in the seamless delivery of precertification services
- Maintains working knowledge of applicable payor adopted criteria
- Review, tracking, trending and appeal of precertification denials as appropriate
- Serves as a resource and precertification subject matter expert for provider office staff
