Address
Form of work1. Works clinical audit accounts with unresolved balances.
2. Prepare and document fact based clinical summaries/appeals based on industry accepted criteria, State/Federal guidelines, evidenced based research and predictive determinations to support account resolution and/or litigation; if clinical review does not meet criteria, leverages co-morbid conditions and other pertinent clinical facts to support account resolution.
3. Perform retrospective (post discharge/post-service) medical necessity reviews to determine appropriateness of level of care documented and provided using nationally accepted criteria, State and Federal Guidelines, evidenced-based research and predictive determinations.
4. Assesses the robustness/strength of already constructed clinical cases and make recommendations regarding most appropriate route of resolution.
5. Monitor the progress and resolution of appealed denials, following-up with third party payors where necessary in order to drive claims to resolution.
6. Identify coding or clinical documentation issues and work with the appropriate stakeholders to correct them in a timely manner and implement root cause mitigation strategies to avoid the issues on future cases.
7. Support the litigation process including interactions with arbitrators/mediators, legal counsel, payor representatives, physicians and case managers.
8. Provide an accurate and comprehensive Executive Summary and detailed monthly account review.
9. Prioritizes and manages multiple tasks simultaneously to effectively anticipate and respond to issues as needed in a dynamic work environment.
10. Perform other work-related duties as assigned or requested.
Graduate of an accredited school of nursing.
Currently licensed as a professional nurse in the Commonwealth of Massachusetts.
Three (3) to five (5) years medical-surgical or similar clinical experience and two (2) years recent experience in dispute management, utilization review and/or case management.
Certified Case Manager (CCM) or Legal Nurse Consultant Certified (LNCC) certification preferred
Position requires excellent analytical and problem solving skills to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis. Thorough knowledge of current standards of medical practice and insurance benefit structures.
Must maintain awareness of current legislation that impacts the appeal & grievance process
Ability to read, write and communicate in English.
Ability to use PC based office productivity tools (e.g. Microsoft Office) as necessary.
