Rehabilitation Authorization and Appeals Specialist PRN

Advocate Health and Hospitals Corporation•Charlotte, NC

1d•Hybrid

About The Position

This position is responsible for understanding and maintaining knowledge of Inpatient Rehabilitation Facilities (IRF) Medicare Criteria and necessary functional and medical complexity that would qualify a given patient for IRF. The specialist will identify patients who would benefit from IRF and make appropriate post-acute discharge recommendations. They will utilize excellent knowledge of appropriate medical and rehab documentation and make recommendations to internal stakeholders to improve documentation that supports IRF admission. This role serves as an expert in managing denials and appeals for the IRF authorization process, diligently communicating with payors to follow up on authorizations and appeals within expedited timeframes. The specialist will manage accurate data gathering and reporting for the No Delay Program for Inpatient Rehabilitation (IPR) and rehab authorizations and appeals in cooperation with Data Analysts, and collaborate with teammates involved in data analysis for reporting outcomes. They will serve as a resource for teammates regarding EPIC Rehab Auth Workflow and articulate reasoning for No Delay/Care First Authorization in a way that is understandable by multiple audiences, including patients, families, and teammates. The specialist will communicate with patients and their families about their specific appeal situation and provide follow-up, obtain necessary Appointment of Representative (AOR) forms, and follow HIM guidance for scanning to the medical record. They will provide timely updates to all necessary teams and document appropriately in the medical record when expedited appeals are upheld and a case will be considered for Administrative Law Judge (ALJ) hearing review. This role serves as a contact person for ALJ offices and communicates with legal assistants regarding matters related to hearings and case files. The specialist will demonstrate a high degree of comfort and confidence working with a team of physicians and lawyers and be prepared to speak in hearings to a judge and legal teams. They will identify and communicate areas for continuous improvement within the defined process of No Delay/Care First Authorizations and demonstrate comfort in navigating, understanding, and communicating information within the electronic health record. Other duties as assigned will also be completed.

Requirements

Bachelor’s Degree required
Licensed clinician required
Trained and qualified clinician such as RN, PT, OT, SLP, NP, PA
Must have a valid driver's license and a vehicle to conduct such travel
Public relations skills preferred
Experience in acute care hospital and/or IPR setting
Communication skills
Organization skills
Attention to detail
Ability to problem solve
Knowledge of Excel, Power Point, and payor portals helpful
Demonstrates knowledge of the principles of growth and development and demonstrates the skills and competency appropriate to the ages, culture, developmental stages, and special needs of the patient population served
Will limit access to protected health information (PHI) to the information reasonably necessary to do the job

Nice To Haves

Clinical experience in inpatient rehabilitation as a PT or OT
Understanding of the inpatient rehabilitation insurance authorization and appeals process
Detail oriented is a must

Responsibilities

Understands and maintains knowledge of Inpatient Rehabilitation Facilities (IRF) Medicare Criteria and necessary functional and medical complexity that would qualify a given patient for IRF
Identifies patients who would benefit from IPR and makes appropriate post-acute DC recommendations
Utilizes excellent knowledge of appropriate medical and rehab documentation and makes recommendations to internal stakeholders to improve documentation that supports IRF admission as appropriate
Serves as an expert in managing denials and appeals for IRF authorization process
Diligently communicates with payors by phone, fax, or email to follow up on authorizations and appeals within the expedited timeframe
Manages accurate data gathering and reporting for No Delay Program for Inpatient Rehabilitation (IPR) and rehab authorizations and appeals in cooperation with Data Analysts
Collaborates with teammates involved in data analysis for reporting outcomes
Serves as a resource for teammates regarding EPIC Rehab Auth Workflow
Articulates reasoning for No Delay/Care First Authorization in a way that is understandable by multiple audiences and for people of different backgrounds including patients, families, and teammates
Communicates with patients and their families about their specific appeal situation and provides follow up
Obtains a properly executed Appointment of Representative (AOR) form as needed and follows HIM guidance for scanning to the medical record
Provides timely updates to all necessary teams and documents appropriately in medical record when expedited appeals are upheld and case will be considered for Administrative Law Judge (ALJ) hearing review
Serves as a contact person for ALJ offices and communicates with legal assistants regarding matters related to hearings and case files
Demonstrates a high degree of comfort and confidence working with a team of physicians and lawyers
Is prepared to speak in hearings to a judge and legal teams
Identifies and communicates areas for continuous improvement within the defined process of No Delay/Care First Authorizations
Demonstrates comfort in navigating, understanding, and communicating information within the electronic health record
Completes other duties as assigned

Benefits

Compensation Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or training
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance
Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program