Pre-Service Nurse Coordinator - PRN

Trinity Health•Conshohocken, PA

2d•Onsite

About The Position

The Clinical Pre-Service Nurse Coordinator is directly responsible for reviewing pre/post service initial denials, securing escalated insurance authorizations, handling escalated medical necessity reviews and coordinating with Patient Access, Mid-Revenue Cycle and Patient Business Service (PBS) to identify opportunities for revenue optimization. This role is supporting the Mid-Atlantic Region which includes: Saint Francis Hospital, Wilmington, DE Mercy Fitzgerald Hospital, Darby, PA Nazareth Hospital, Philadelphia, PA St. Mary Medical Center, Langhorne, PA. Trinity Health is one of the largest not-for-profit, faith-based health care systems in the nation, with 121,000 colleagues and nearly 36,500 physicians and clinicians caring for diverse communities across 27 states. The organization is nationally recognized for care and experience, including 101 hospitals, 126 continuing care locations, the second largest PACE program in the country, 136 urgent care locations, and many other health and well-being services. Rooted in its Mission and Core Values, Trinity Health honors the dignity of every person and recognizes the unique perspectives, experiences, and talents each colleague brings, fostering a culture that nurtures a healing, safe environment for all.

Requirements

PA Registered Nurse or Licensed Vocational Nurse/Licensed Practical Nurse and graduate of an accredited school of nursing.
At least two (2) years of nursing experience.
Minimum two (2) years of pre-certification/prior approval clinical denial unit management experience.
Demonstrated knowledge of patient access, revenue cycle and denial management functions.
Strong organizational, task prioritization, resource management skills.
Excellent written and oral communication & presentation skills.
May be require travel up to 10% between locations within the Trinity Mid-Atlantic Region.

Nice To Haves

Certification and/or membership in AAPC, AHIMA, HFMA, AAHAM, NAHAM.
Working knowledge of medical terminology, and medical record coding experience (ICD-9, CPT, HCPCS).
Working knowledge of Epic Prelude and Resolute, including associated work queues.

Responsibilities

Works closely with Physician Providers to assure that the proposed intensity of service is in alignment with the severity of illness and accurately documented to support level of care determinations and required authorizations.
Investigates denials and root causes and tracks and reports trends to remediate issues and assist with internal process improvement.
Leverages clinical knowledge and standard procedures to ensure timely attention to denials as requested by PBS and assists in the research and application of regulatory policies to support administrative appeals.
Communicates pertinent clinical information to Physicians, Medical Directors, and CFO, as indicated, regarding evaluation of medical appropriateness and/or payer determinations.
Understands clinically complex medical situations and communicates appropriately with insurers as needed.
Maintains a working knowledge of applicable Federal, State, and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
Utilizes working knowledge of basic coding guidelines for medical necessity and insurance authorization escalations and/or denials.
Awareness of how to navigate payer websites to occasionally validate insurance eligibility and authorizations.
Familiarity with the construction of professional appeals in response to denied claims.