What are the responsibilities and job description for the Clinical Review and Appeals Specialist position at Intersect Healthcare?
Covering Detroit Metro Area - Facility Onsite Position
Summary: This position will be responsible for managing, monitoring, and coordinating all ADRs (Additional Documentation Requests), Medical Record Requests related to payer audits.
Clinical Review Specialist 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:
Summary: This position will be responsible for managing, monitoring, and coordinating all ADRs (Additional Documentation Requests), Medical Record Requests related to payer audits.
Clinical Review Specialist 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 standing
- Minimum of 5 years in health care, preferably long-term care environment
- MDS experience and RAC-CT preferred
- Understanding of Point Click Care (PCC) software
- Knowledge of Billing, codes, abbreviations and universal billing forms
- Understanding 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.
- 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