Clinical Revenue Management

Overview

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values - integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.

Under the general direction of the Senior Manager, Clinical Revenue Management (CRM), the Clinical Revenue Management Specialist (CRMS) performs a wide range of system wide clinical revenue management activities in an attempt to prevent insurer denials, enhance revenue, and to recover payment for services that have been denied. Responsible for the collection of denial and appeal data as well as other clinical documentation when necessary. The CRMS works collaboratively with other members of the CRM department, health care team, Care Coordination, Verification, Clinical Finance Operations (CFO), Contracting and Corporate Business Services (CBS).

EEO/AA/Disability/Veteran
Responsibilities

• 1. Follows department established Fax Review protocols. Extracts and summarizes pertinent clinical information to transmit to payors for reimbursement.
• 2. Proactively identifies potential concerns regarding clinical eligibility for admission and/or continued stay reviews and addresses with Care Coordination.
• 3. Coordinates reconsiderations and/or peer to peer reviews for concurrent denials. Follows departmental policy to communicate internally with physicians, care coordination, utilization nurses.
• 4. Ensures accuracy of patient status via pre bill or post remit CVT per departmental policy.
• 5. Identifies cases for outlier referral or alternate level of care payment per departmental policy.
• 6. Responds to external audits and inquires not limited to OIG, IPRO, QIO and RAC. Documents accordingly in EPIC.
• 7. Establishes a system to follow up with payers/managed care organizations regarding outstanding denials and addresses identified payor issues
• 8. Acts as a consultant and resource to the financial and care coordination departments regarding Utilization insurance and payer issues.
• 9. Ensures inpatient clinical payor denials are reviewed for appeal potential. Files formal appeals with the payors requesting reconsideration of the denied services.
• 10. Works with our members of CBS team on inpatient technical denials and precertification issues.
• 11. Identifies trends and consistent barriers and work with the CBS Management Teams and the YNHHS health care team to support resolution. Intervenes when necessary to correct delays and eliminate/reduce negative financial outcomes. Collaborates with appropriate individuals and departments to ensure appropriate reimbursement.
• 12. Communicates as needed with, MDS, payors and governmental contractual agencies regarding denials and appeals. Develops strong working relationships with payors to support collaborative efforts in ensuring hospital reimbursement.
• 13. Works collaboratively with CBS to support monthly documentation of provider liable dollars. Tracks, documents and reports denials and appeals by payor. In collaboration with Manager of the department developed a statistical tracking system that supports the quantification of all department activities, cost avoidance strategies, and denial appeal facilitation.
• 14. Tracks key indicators in CRM monthly dashboard.
• 15. Along with other members of the health care clinical and financial team, acts as a patient advocate to support ongoing medical intervention and treatment. Exhibit awareness of ethical/legal/confidential issues concerning patient care and treatment and support the adherence to such practice.
• 16. Attends Ad Hoc and regular meetings of both the hospital and system Utilization Review and Denial Committees.
• 17. Performs miscellaneous duties as required or requested.

Qualifications

EDUCATION

Current licensure in the State of Connecticut as Registered Nurse with a Bachelors of Science Degree. Masters Degree preferred.

EXPERIENCE

Strongly preferred a minimum of five years of relevant clinical experience in hospital acute care along with relevant experience in case management, care coordination, and/or utilization management in a hospital or insurance setting. Strongly preferred knowledge of finance and billing practices

LICENSURE

Current licensure in the State of Connecticut as Registered Nurse.

SPECIAL SKILLS

Excellent communication, negotiation and organizational skills. Adaptability to a wide variety of interpersonal encounters with the entire hospital team. Comprehensive understanding in use of medical record to extract data. Working knowledge of third party and prospective payment systems. Computer/PC literacy required. Proficient in Microsoft Office including but not limited to Word, Outlook and Excel. Knowledge of EPIC strongly preferred. Will be trained in use of professionally recognized criteria, ICD10-CM Coding, Diagnostic Related Grouping (DRG). Must be able to work collaboratively and independently. Must be flexible with responsibilities in order to meet departmental needs.

YNHHS Requisition ID

119351