Prebill Denials RN
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POST DATE 9/13/2016
END DATE 10/12/2016
Orange Park, FL
JOB DESCRIPTIONJob Code: 26466-123569
Work From Home
Parallon The Prebill Denials Nurse will review post discharge, prebill accounts that do not have an authorization on file, ALOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payor that require clinical expertise. Communicates with third party payors to resolve discrepancies prior to billing. Accurately and concisely documents all communications and action taken on the account in accordance with policies and procedures. Escalate medical review request and/or denial activities to management as needed.
Supervisor SSC Denials Director
. Obtain authorizations for post discharge, prebill accounts . Perform re-certification for additional days on post discharge, prebill accounts . eRequest queues as determined during program implementation
Duties (included but not limited to):
Work post discharge, prebill accounts efficiently and effectively on a daily basis to resolve accounts with no auth numbers, ALOS vs. authorized days or other discrepancies . Evaluates clinical documentation on multiple patient accounts and escalates issues through the established chain of command . Perform accurate and timely documentation of all review activities based on policy and procedure
. Demonstrates a working knowledge of managed care agreements based on available resources which may include and not be limited to payer UM Manual, policy and procedure, facility contract information. Escalates variations timely.
. Work assigned accounts in eRequest to resolve outstanding issues . Report insurance denial trends identified during daily operational assignments . Contact facilities, physicians offices and/or insurance companies to resolve denials/appeals if needed . Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives;
monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives.
. Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous . Communicates effectively and professionally with physicians, hospital staff, and outside agencies . Adhere to all policies and procedures, including, attendance, phone and internet usage, break utilization, etc. . Participate in education and training as needed
. Establish and maintain relationships with all customers . Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous . Adheres to established policy and procedure and standards of care; escalates issues through the established Chain
of Command timely . Demonstrates commitment to teamwork and cooperation . Practice and adhere to the Code of Conduct philosophy and Mission and Value Statement . Other duties as assigned
Parallon - Knowledge, Skills & Abilities . Customer Orientation establishes and maintains long term customer relationships, building trust and respect by
consistently meeting and exceeding expectations . Communication -communicates professionally, clearly and concisely . Interpersonal skills ability to establish and maintain collaborative and effective working relationships . PC Skills demonstrates advanced proficiency in Microsoft Office applications and others data mining software . Policies & Procedures -demonstrates knowledge and understanding of organizational policies, procedures and
systems . Basic skills demonstrates ability to organize, perform and track multiple tasks accurately in short timeframes and have ability to work quickly and accurately in a fast-paced environment while managing multiple demands . Clinical skills ability to read/ interpret medical record documentation and present the clinical data obtained in an organized, concise dialogue to the payor in order to obtain auth and/or resolve other issues.
. !ssociate s Degree or higher preferred
. Utilization Review, appeals, denials, managed care contracting, experienced preferred
CERTIFICATE/LICENSE RN or LPN/LVN with current state licensure
Last Edited: 09/01/2016