RN Patient Flow and Throughput Utilization and Appeals Specialist

Hurley Medical Center•Flint, MI

About The Position

GENERAL SUMMARY : RN Patient Flow and Throughput Utilization and Appeals Specialist operates with an effort to eliminate clinical barriers to acute progression of care and post- acute discharge planning while aligned with the mission of the organization. This registered nurse role supports the Care Coordination department throughout the medical center in addressing and resolving insurance issues related to access to DME, medications, levels of care post- acute, and appeals for services. Key responsibilities include building and maintaining relationships with physicians and clinical staff so as to bridge the gap between them and the payer matrices as needed to support throughput and reimbursement for the organization. Requires strong clinical knowledge and judgment. Serves as the primary liaison between operational areas and appeals processes related to progression of care. Participates in quality assessment and continuous quality improvement activities. Works independently and incorporates positive patient experience tools and practices into their daily workflows. Performs all job duties and responsibilities in a courteous and customer- focused manner according to the Hurley Family Standards of Behavior. SUPERVISION RECEIVED : Works under the direct supervision of the Director of Care Coordination and Clinical Risk Management or designee who assigns work and reviews for effectiveness and conformance with policies and procedures.

Requirements

Graduation from an accredited School of Nursing
3 years of clinical experience as a registered nurse in an acute hospital facility with experience with behavior health preferred.
Working knowledge of utilization management and/ or experience preferred.
Current knowledge of governing regulations, third party payer utilization, quality mandates, reimbursement requirements, and standards associated with behavior health utilization review and management
Ability to work independently, set priorities, organize work, and make decisions in accordance with established policies and procedures while maintaining flexibility
Ability to compile, analyze, and evaluate data and prepare accurate reports from such data
Current knowledge of third party payer fraud and abuse regulations
Licensed as a Registered Nurse from the State of Michigan

Responsibilities

Collaborates with the Care Coordination department, Transitions Team, and acute clinicians to support and resolve denials and appeals for post- acute care facilities, medications, DME, IV infusion, outpatient hemodialysis and other barriers including barriers related to social determinants of health.
Communicates with peers, clinicians, and providers to identify and resolve clinical barriers to access and authorization for next level of care and/ or post- acute resources.
Completes, monitors, and connects patient authorization activities as required by various payers.
Communicate authorization requirements, coverage limitations, and clinical rationale for determinations.
Documents activities in the patient record and required payer communication modes.
Continuously research, designs, and implements workflows and monitors, tracks, and trends reporting based on up-to-date payer and government guidelines for all authorizations and barriers.
Understands the concept of analyzing cases and applying medical necessity criteria in order to perform concurrent and retrospective review including monitoring the documentation of the ongoing assessment, treatment, and intervention of patients in the acute hospital and behavioral health complex.
Educates, trains, and supports within the Care Coordination department end users and HMC operational leaders and clinical staff throughout the medical center related to utilization and operation of any tools or reports related to authorization and appeals processes.
Instructs and keeps staff current on payer documentation expectations and medical necessity criteria.
Provides all education with a goal of reducing denials and appeals from the front end of processes.
Functions as the Care Coordination representative on the Enterprise Authorization Committee to describe our barriers and successes to that entity.
Serves as an advisor in creation and maintenance of any new services to determine authorization needs and process requests that impact acute and post-acute workflows.
Manages, reviews, and resolves denied insurance claims for the inpatient behavioral health complex at HMC, working closely in alignment with the Behavioral Health Utilization Management Coordinator.
Analyzes denied claims and composes appeal letters that incorporate all evidence required to support the necessity of the behavioral health service in its entirety and fiscal wholeness for each case within the specialty hospital.
Monitors, measures, and communicates to stakeholders re: the performance of the clinical initiatives of the service and attempts for resolution of denied cases in order to identify key areas for improvement.
Utilizes the EMR system efficiently and effectively and provides sufficient and clear documentation of all actions taken.
Works with the Patient Access Department to verify patient information and insurance coverage, updates whenever necessary.
Consistently works with teammates and leadership to help improve workflows, update processes, and foster a positive work culture.
Performs other job duties as required/ assigned.
Utilizes new improvements and/ or technology that relate to the job assignment.
Involvement in special projects as needed.