Revenue Cycle Appellate, Clinician - Remote
As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide.
We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare.
Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare.
Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!Job SummaryThe Revenue Cycle Clinician for the Appellate Solution is responsible for:
Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review Preparing and documenting appeal based on industry accepted criteria.
Essential Duties And ResponsibilitiesInclude the following.
Others may be assigned.
Performs retrospective (post -discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual(R) or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits.
Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual(R) criteria (Acute, Procedures, etc).
If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal.
Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process.
Adhers to the department standards for productivity and quality goals.
Ensuring accounts assigned are worked in a timely manner based on the payor guidelines.
Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual(R), VI, HPF, as well as competency in Microsoft Office.
Demonstrates basic patient accounting knowledge ie UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc.
Additional
Responsibilities:
Serves as a resource to non-clinical personnel.
Provides CRC leadership with sound solutions related to process improvementAssist in development of policy and procedures as business needs dictate.
Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.
QualificationsConifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment activity.
This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
Knowledge, Skills, AbilitiesTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
The requirements listed below are representative of the knowledge, skill and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Demonstrates proficiency in the application of medical necessity criteria, currently InterQual(R)Possesses excellent written, verbal and professional letter writing skillsCritical thinker, able to make decisions regarding medical necessity independentlyAbility to interact intelligently and professionally with other clinical and non-clinical partnersDemonstrates knowledge of managed care contracts including reimbursement matrixes and termsAbility to multi-taskAbility to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.
Ability to conduct research regarding off-label use of medicationsEducation / ExperienceInclude minimum education, technical training, and/or experience required to perform the job.
Must possess a valid nursing license (Registered or Practical/Vocational)Minimum of 5 years recent acute care experience with the last 2 years in a facility environmentMedical-surgical/critical care experience preferredMinimum of 2 years UR/Case Management experience within the last 2 yearsManaged care payor experience a plus either in Utilization Review, Case Management or AppealsPatient Accounting experience a plusPrevious classroom led instruction on InterQual(R) products (Acute Adult, Peds, Outpatient and Behavioral Health) preferredCERTIFICATES, LICENSES, REGISTRATIONSCurrent, valid RN/LPN/LVN licensureCertified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferredPHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to lift 15-20lbs Ability to travel approximately 10% of the time; either to facility sites, National Insurance Center (NIC) sites, Headquarters or other designated sitesAbility to sit and work at a computer for a prolonged period of time conducting medical necessity reviewsWORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.
OtherMay require travel - approximately 10%Interaction with facility Case Management, Physician Advisor is a requirement.
Job:
Conifer Health SolutionsPrimary Location:
Frisco, TexasJob Type:
Full-timeShift Type:
Days.
Estimated Salary: $20 to $28 per hour based on qualifications.
We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare.
Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare.
Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!Job SummaryThe Revenue Cycle Clinician for the Appellate Solution is responsible for:
Recovering revenue associated with disputed/denied clinical claims or those eligible for clinical review Preparing and documenting appeal based on industry accepted criteria.
Essential Duties And ResponsibilitiesInclude the following.
Others may be assigned.
Performs retrospective (post -discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual(R) or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits.
Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual(R) criteria (Acute, Procedures, etc).
If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal.
Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
Demonstrates ability to critically think and follow documented processes for supporting the clinical appellate process.
Adhers to the department standards for productivity and quality goals.
Ensuring accounts assigned are worked in a timely manner based on the payor guidelines.
Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, nThrive, eCARE, Authorization log, InterQual(R), VI, HPF, as well as competency in Microsoft Office.
Demonstrates basic patient accounting knowledge ie UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, denials management, etc.
Additional
Responsibilities:
Serves as a resource to non-clinical personnel.
Provides CRC leadership with sound solutions related to process improvementAssist in development of policy and procedures as business needs dictate.
Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.
QualificationsConifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment activity.
This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
Knowledge, Skills, AbilitiesTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily.
The requirements listed below are representative of the knowledge, skill and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Demonstrates proficiency in the application of medical necessity criteria, currently InterQual(R)Possesses excellent written, verbal and professional letter writing skillsCritical thinker, able to make decisions regarding medical necessity independentlyAbility to interact intelligently and professionally with other clinical and non-clinical partnersDemonstrates knowledge of managed care contracts including reimbursement matrixes and termsAbility to multi-taskAbility to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.
Ability to conduct research regarding off-label use of medicationsEducation / ExperienceInclude minimum education, technical training, and/or experience required to perform the job.
Must possess a valid nursing license (Registered or Practical/Vocational)Minimum of 5 years recent acute care experience with the last 2 years in a facility environmentMedical-surgical/critical care experience preferredMinimum of 2 years UR/Case Management experience within the last 2 yearsManaged care payor experience a plus either in Utilization Review, Case Management or AppealsPatient Accounting experience a plusPrevious classroom led instruction on InterQual(R) products (Acute Adult, Peds, Outpatient and Behavioral Health) preferredCERTIFICATES, LICENSES, REGISTRATIONSCurrent, valid RN/LPN/LVN licensureCertified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferredPHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to lift 15-20lbs Ability to travel approximately 10% of the time; either to facility sites, National Insurance Center (NIC) sites, Headquarters or other designated sitesAbility to sit and work at a computer for a prolonged period of time conducting medical necessity reviewsWORK ENVIRONMENT The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.
OtherMay require travel - approximately 10%Interaction with facility Case Management, Physician Advisor is a requirement.
Job:
Conifer Health SolutionsPrimary Location:
Frisco, TexasJob Type:
Full-timeShift Type:
Days.
Estimated Salary: $20 to $28 per hour based on qualifications.
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