SCOPE OF POSITION:
Responsible for analyzing patient records to determine legitimacy and necessity of medical services in compliance with government reimbursement policies. Review may be prior authorization, concurrent with service or post service. Review findings may be referred to a physician advisor for final determination. Support the organization’s mission, vision, and values by exhibiting the following behaviors: Honesty, Excellence, Accountability, Respect and Teamwork.
ESSENTIAL JOB FUNCTIONS:
1. Review each selected record accurately and according to AFMC, state and federal policies and procedures.
2. Function as a resource for non-clinical staff by providing oversight and follow-up for clinical related questions or issues
3. Write effective and accurate review summaries and submit within appropriate time frame.
4. Refer all cases that do not meet established medical necessity criteria for approval to a peer clinical reviewer on a daily basis.
5. Maintain files for recording and reporting in accordance with established procedures.
6. Perform site surveys as required or directed if relevant to your department. Must be able to travel within the State as needed to accomplish required site visits if relevant to your department.
7. Prepare monthly reports and/or statistics as directed.
8. Communicate effectively with internal and external clients. Upon request, verbally informs patients, facility personnel, the attending physician and other ordering providers, and health professionals of specific utilization management requirements and procedures
9. Seek direction from Manager Clinical Services, Director Clinical Services, Associate Medical Director, or Medical Director for any clinical related questions or issues during the review process.
10. Daily quotas may be added to meet contract deliverables as needed.
11. Adhere to format, content, and style guidelines, giving consideration to usability and ensuring accuracy, consistency, and quality.
12. Follow AFMC, state and federal protocols regarding data confidentiality/security and HIPAA compliance.
13. Additional duties as assigned.
KNOWLEDGE, SKILLS, AND ABILITIES:
• Intermediate level computer skills (Excel, Word, Access, PowerPoint, and Outlook).
• Type 40 wpm.
• Exceptional skills in business English and spelling are required.
• Ability to maintain confidentiality.
• Strong oral and written communication skills.
• Creativity.
• Customer service.
• Ability to meet deadlines.
• Attention to detail.
• Flexibility.
• Knowledge of ICD 9/ICD 10 Coding.
• Knowledge of HIT/EHR.
• Medical terminology.
• Ability to work collaboratively and independently to achieve stated goals.
• Initiative.
• Ability to relate professionally and positively with staff, business partners, customers, constituents, recipients, and the public.
• Ability to multitask.
• Ability to prioritize.
• Strong organizational skills.
• Problem solving skills.
• Professionalism.
• Project management skills.
• Ability to read, interpret and apply laws, rules, and regulations.
• Knowledge of quality improvement processes and techniques.
• Time management skills.
• Ability to travel, including overnight travel.
Demo