Clinical Pre-Service Nurse Auditor

Premier Medical Resources•Houston, TX

5d•Onsite

About The Position

Revenue Cycle Management is looking for a Clinical Pre-Service Nurse Auditor to join their team. The Clinical Pre-Service Auditor will provide/confirm precertification of and all authorization requests. The Clinical Pre-Service Auditor will assist with minimizing denials by way of ensuring medical criteria / medical necessity is met prior to services are scheduled. This process includes clinical judgement, utilization management, application, understanding of payor protocols requirements, and verification of medical necessity utilizing nationally recognized criteria.

Requirements

Nurse in good standing, currently licensed in the State of Texas without stipulations in practice as a Licensed Vocational Nurse
Three (3) years of hospital experience in various clinical areas.
One (1) year utilization review, authorization, or case management experience
Familiar with hospital coding and billing processes.
Knowledge of InterQual/Milliman guidelines, Medicare guidelines
Above average verbal and written communication skills
Analytical, Mathematics, Medical Terms
Must be able to interact successfully in a culturally diverse environment

Responsibilities

Works as part of integrated team and is involved in reviews of authorization requests and communicates with the physicians and clinic when additional information is needed.
Performs activities that include obtaining payer authorization for outpatient services that require notification/authorization based on payer specific guidelines.
Maintains a thorough understanding of the plan's provider contracts, authorization requirements and ongoing follow-up and re-evaluation of clinical departments/areas as requested or needed for authorization review.
Compiles and maintains established payer protocols to determine the medical appropriateness of ordered pre and post scheduled services.