Rehabilitation Authorization and Appeals Specialist PRN

American Addiction Centers • Charlotte, NC

3d • Onsite

About The Position

This position is responsible for understanding and maintaining knowledge of Inpatient Rehabilitation Facilities (IRF) Medicare Criteria and the necessary functional and medical complexity for IRF qualification. The specialist identifies patients who would benefit from IRF and makes appropriate post-acute discharge recommendations. They will utilize excellent knowledge of appropriate medical and rehab documentation, making recommendations to internal stakeholders to improve documentation supporting 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. They will collaborate with teammates involved in data analysis for reporting outcomes and serve as a resource for teammates regarding EPIC Rehab Auth Workflow. Additionally, the specialist will articulate the reasoning for No Delay/Care First Authorization in a way that is understandable by multiple audiences, including patients, families, and teammates, and communicate with patients and their families about their specific appeal situation, providing follow-up. They will obtain a properly executed Appointment of Representative (AOR) form as needed and follow HIM guidance for scanning to the medical record. The role involves providing timely updates to all necessary teams and documenting appropriately in the medical record when expedited appeals are upheld and a case will be considered for Administrative Law Judge (ALJ) hearing review. The specialist will serve as a contact person for ALJ offices and communicate with legal assistants regarding matters related to hearings and case files, demonstrating a high degree of comfort and confidence working with a team of physicians and lawyers. They will be prepared to speak in hearings to a judge and legal teams and identify and communicate areas for continuous improvement within the defined process of No Delay/Care First Authorizations. The role requires comfort in navigating, understanding, and communicating information within the electronic health record and completing other duties as assigned.

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.
• Experience in acute care hospital and/or IPR setting.
• Communication skills.
• Organization skills.
• Attention to detail.
• Ability to problem solve.
• 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 Preferred (RN ok).
• Understanding of the inpatient rehabilitation insurance authorization and appeals process.
• Public relations skills preferred.
• Knowledge of Excel, Power Point, and payor portals helpful.

Responsibilities

• Understand and maintain knowledge of Inpatient Rehabilitation Facilities (IRF) Medicare Criteria and necessary functional and medical complexity that would qualify a given patient for IRF.
• Identify patients who would benefit from IPR and make appropriate post-acute DC recommendations.
• Utilize excellent knowledge of appropriate medical and rehab documentation and make recommendations to internal stakeholders to improve documentation that supports IRF admission as appropriate.
• Serve as an expert in managing denials and appeals for IRF authorization process.
• Diligently communicate with payors by phone, fax, or email to follow up on authorizations and appeals within the expedited timeframe.
• Manage accurate data gathering and reporting for No Delay Program for Inpatient Rehabilitation (IPR) and rehab authorizations and appeals in cooperation with Data Analysts.
• Collaborate with teammates involved in data analysis for reporting outcomes.
• Serve as a resource for teammates regarding EPIC Rehab Auth Workflow.
• Articulate 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.
• Communicate with patients and their families about their specific appeal situation and provide follow up.
• Obtain a properly executed Appointment of Representative (AOR) form as needed and follow HIM guidance for scanning to the medical record.
• Provide timely updates to all necessary teams and document appropriately in medical record when expedited appeals are upheld and case will be considered for Administrative Law Judge (ALJ) hearing review.
• Serve as a contact person for ALJ offices and communicate with legal assistants regarding matters related to hearings and case files.
• Demonstrate a high degree of comfort and confidence working with a team of physicians and lawyers.
• Be prepared to speak in hearings to a judge and legal teams.
• Identify and communicate areas for continuous improvement within the defined process of No Delay/Care First Authorizations.
• Demonstrate comfort in navigating, understanding, and communicating information within the electronic health record.
• Complete other duties as assigned.

Benefits

• Competitive compensation
• Generous retirement offerings
• Programs that invest in your career development
• 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

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level