Clinical Reviewer / Care Manager | 0.8 PT

Phelps Health•Phelps Health Hospital, MO

11d•Onsite

About The Position

The Clinical Reviewer assists with data collection, entry and generation of reports; coordinates communication between Patient Financial Services, Third party Payers, patients, and physicians; and performs certifications, authorizations, concurrent reviews, and appeals. The clinical reviewer will be responsible for reviewing inpatient and observation patients and performing certifications/authorizations for Medicare, Medicaid, Commercial, and Medicare HMO third party payers.

Requirements

Graduate of an approved practical nursing program or an equivalent combination of education and experience.
At least two (2) years clinical experience in Utilization Management, Social Services, and/or Quality Management required.
Lifting up to 35 lbs., turning activities and nearly constant walking required.
Standing, turning, carrying, pushing, pulling, stooping, crouching, twisting, and reaching.

Nice To Haves

Experience working with third party payers is preferred.

Responsibilities

Performs pre-certification, concurrent, retrospective and appeal review in an accurate and timely manner to assure reimbursement for Phelps Health.
Acts as liaison between Patient Financial Service members and Care Management team.
Works cooperatively with physician offices, communicating necessary information to assure reimbursements, collaborates with physicians and makes appropriate recommendations regarding medical necessity for admission, continued stay, or alternative treatment facilities, agencies, and/or resources.
Assists with communicating discharge-planning information to Third Party Payors and care providers.
Completes appeals, back certifications, and retrospective reviews for Denial, Prevention and Recovery.
Communicates directly with the health care team during the denial process to include issuing denial letters and assisting in appealing hospital denials prior to and after the discharge of a patient.