What are the responsibilities and job description for the Clinical Review and Appeals Specialist position at Hyper Care Management LLC?
Clinical Review and Appeals SpecialistPriority will be given to those who reside in MichiganHyper Care seeks a top-notch Clinical Review and Appeals Specialist who has a strong work ethic, exceptional organization skills, pays attention to detail, and has the desire to acquire and apply new skills within our fast-paced environment. This position will work closely with our ADR Director in supporting skilled nursing centers throughout Michigan.Are you a Nurse with MDS knowledge? If yes, we would like to speak with you! Apply today!We offer excellent benefits including:Competitive payTuition assistanceStudent loan repayment programCompany paid life insurancePaid vacation time and paid holidaysHealth, dental, visionAn array of supplementary policies, including flexible spending accounts and healthcare savings accounts.401(k)PLUS the potential for growth!Summary:The Clinical Review and Appeals Specialist will be responsible for managing, monitoring, and coordinating all ADRs (Additional Documentation Requests), Medical Record Requests related to payer audits.Duties include, but are not limited to, processing the initial ADR and continuing through all levels of appeals for a caseload of assigned facilities. Continuous communication and training with facility staff is required, as well as daily/weekly review of online portals for new requests and follow-up of outstanding ADR statuses. Review requests for accuracy and thoroughness prior to submission to auditing organization.Experience required with medical records, Clinical Reimbursement, RAI process, Medicare Conditions of Participation, Managed Care, and state specific documentation guidelines.Qualifications:Licensed Nurse in good standingMinimum of 5 years in health care, preferably long-term care environmentMDS experience and RAC-CT preferredUnderstanding of Point Click Care (PCC) softwareKnowledge of Billing, codes, abbreviations and universal billing formsUnderstanding of ICD codes and HIPPS.Knowledge of nursing and medical practice and procedures, as well as laws, regulations and guidelines which pertain to long term care.Ability to analyze medical records to determine appeal opportunities and compose appeal letter as necessary.Ability to read, write, comprehend and communicate in English. Follow oral and written instructions.Able to make independent decisions and possess problem-solving skills.Must function independently and have flexibility, personal integrity and the ability to work effectively with co-workers, managers, other personnel and support agencies.Job Functions:Follow regulations to plan, schedule and assure timely completion of all components of the ADR process for each resident at assigned facilities.Work with IDT team to gather all pertinent information and save it to the public drives. Review medical records, financial records and PCC for completion, accuracy and quality.Utilize online portals and other online resources as necessary to complete job duties.Utilize Excel (or other software) for documenting and tracking ADRs and Appeals. Analyzes findings, ADR log data, appeals outcomes, current practices/processes, etc. to map out ADR trends.Collaborates with clinical and RAI teams to assist in developing best practices, process change related to documentation, coding, UDAs, etc.Provides ongoing education to center and regional teams as it relates to ADR activity, trends, and findings.Complete monthly SNF Clinic Training modules.Complete all other duties, as assigned.Working Conditions and Principal Contacts:Maintain HIPAA compliance.Follow and practice safely within the policies and procedures.Complete all required training to assure prevention of workplace violence, harassment, and discrimination.Report any concerns related to patient safety, or environmental issues.This position does not offer flexible hours. On-call coverage is required.Knowledge/Skills/Abilities: Dress professionallyAttend, participate and present mandatory in-services and meetings.Adhere to and uphold the corporate compliance code of conduct and program.Actively and enthusiastically support the philosophy and goals of the organization.Perform other tasks, as requested, to meet the goals and objectives of the organization.
Salary : $70,300 - $88,800