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ScionHealth is committed to a culture of service excellence as demonstrated by our employees’ adherence to the service excellence principles of Pride, Teamwork, Compassion, Integrity, Respect, Fun, Professionalism, and Responsibility.
Job Summary: The Clinical Appropriate Management (CAM) Specialist combines strong relationship building skills and clinical knowledge to manage the Authorization and Appeals Management processes. Responsible for investigating and processing authorizations. Primary duties include; review of prospective, retrospective or concurrent medical records of denied services for medical necessity, as well as processing authorizations. Serves as a liaison with marketing, Managed Care and administration of the facilities. Coordinates the managed care determinations and distributes information to the marketing and admissions support staff across multiple markets. Identifies information needed from the referring hospital to finalize the authorization.
Essential Functions:
- Extrapolates and summarizes essential medical information to obtain authorization for admission to Kindreds Level of Care.
- Prepares recommendations to request reconsideration of denial determination in attempt to have denied authorization requests overturned.
- Ensures authorization requests are processed timely to meet regulatory timeframes.
- Reviews and analyzes Medical Necessity, assessing documentation for specific criteria related to severity of illness, and level of care appropriateness. Generates written appeals to medical necessity-based payor denials. Authorizations and Appeals will be processed on behalf of the physician, combining clinical and regulatory knowledge in efforts to have consideration of authorization.
- Documents authorization information in relevant mainframe tracking systems.
- Effectively builds relationships with marketing team, admission coordinators/clinical staff and managed care team, to coordinate the patient admission functions in keeping with the mission and vision of the hospital.
- Coordinates and facilitates Pre-admission authorizations for patients from the referral sources.
- Identifies /reviews medical record information needed from referring facility.
- Applies appropriate clinical guidelines to pre-authorization determination process.
- Acts as a liaison with the Marketing team through every stage of the authorization process through determination. Initiates appeals process as appropriate.
- Facilitates and coordinates physician-to-physician communication as appropriate to support the authorization process.
- Communicates with Medical Advisors of managed care company as necessary.
- Identifies and communicates specific patient needs for equipment, supplies, and consult services as related to prior authorization requirements.
- Provides hospital team with needed precert information on pending / new admissions.
- Maintains a state-of-the-art knowledge of areas of responsibility and develops and follows a program of continuing education.
- Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct, its policies and procedures, the Corporate Compliance Agreement, applicable federal and state laws, and applicable professional standards.
- Communicates to receiving Kindred facility when clinical authorization and financial approval is complete, following standard authorization process.
- Initiate precertification upon receipt of commercial / managed care insurance verifications, and supportive clinical documentation.as appropriate.
- Coordinate with managed care payor on all coverage issues.
Qualifications
Education:
- Bachelor’s degree in clinical area strongly preferred.
Licenses/Certification:
- Active Healthcare professional licensure required.
- Registered Nurse strongly preferred; LPN, Respiratory Therapist, Physical Therapist, considered.
Experience:
- Three years’ healthcare experience
- Proven history of effective relationship management in a matrix reporting structure
