Licensed Practical Nurse LPN - Clinical Review Specialist - Mon - Fri 8:00am - 5:00pm - Hybrid

Northeast Georgia Health System•Gainesville, GA

5d•Hybrid

About The Position

Clinical Review Specialist works with Medicaid and Disability team and other key stakeholders (e.g., Case Management, Social Workers, Patient Access Service Center teams) in order to provide clinical screening assessments of prospective Medicaid or Disability candidates and will assist patients and families with navigating through the Medicaid or Disability application process. The position will further provide medical record analysis and other clinical expertise in order to support the functions of the department; for example will review medical records in order to make a determination of emergency services provided. This position will also provide coverage for precertification tasks as needed.

Requirements

LPN
Associates Degree
A minimum of three (3) years in professional nursing and at least one year of UR, Case Management and/or Auditing experience
Ability to analyze medical records, including but not limited to physician orders, clinical notes, and coding
Exceptional research and problem-solving skills
Deep knowledge of Patient Financial Services processes and procedures, including governmental guidelines and protocols, the components of full verification, and payer information / medical necessity requirements
Exemplary customer service skills and the ability to assist others in a pleasant, courteous and professional manner
Excellent oral and written communication skills required
Ability to serve as a clinical expert resource to all Medicaid and Disability personnel and other internal and external departments

Nice To Haves

RN
Bachelors Degree

Responsibilities

Works with Medicaid and Disability team and other key stakeholders (e.g., Case Management, Social Workers, Patient Access Service Center teams) in order to provide clinical screening assessments of prospective Medicaid or Disability candidates.
Completes timely and accurate review of patient's medical record in order to determine medical necessity of procedure(s) performed, patient's long-term prognosis and follow-up care needs; determines if criteria for emergency services were met via records reviews and completes requisite forms.
Navigates patient and or patient's family through the application process for Medicaid or Disability; also supports/performs tasks related to the precertification, claims denials, and appeals processes.
Performs insurance defense audits.
Audits applications and appeal documentation to ensure accuracy and completeness.
Communicates and implements, in an accurate and timely manner, process change as needed to accommodate high volume and other unforeseen circumstances that may arise.
Completes precertification functions as needed.
Participates in education and training efforts to maintain competency in ever changing environment.
Maintains clinical licensure.
Teams with other departments to improve performance of the revenue cycle.
Provides support and guidance to problem-solving and process improvement initiatives.
Performs other duties as assigned or requested.