Medical Necessity Review Nurse - West Virginia University Health System : Job Details

Welcome! We're excited you're considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you'll find other important information about this position.The Medical Necessity examines the medical records and performs front end medical necessity review of ordered services through the pre-authorization services. In this role, the associate will assess provider education opportunities and coordinate feedback sessions established by authorization requirement and payer policies. This role will serve as a subject matter expert (SME) as related to medical necessity for the revenue cycle department. This position will collaborate with other departments, as necessary to ensure medical necessity is established for services requested/rendered.MINIMUM QUALIFICATIONS:EDUCATION, CERTIFICATION, AND/OR LICENSURE:1. Associate degree (ASN) in Nursing OR bachelor's degree in nursing and passing the National Council Licensure Examination (NCLEX) for Registered Nurses OR Licensed Practical Nurse and passing the NCLEX-PN for LPNEXPERIENCE:1. Three (3) years' experience in direct patient care experience OR hospital revenue cycle and authorization management experiencePREFERRED QUALIFICATIONS:EDUCATION, CERTIFICATION, AND/OR LICENSURE:1. Registered Nurse or Licensed Practical NurseEXPERIENCE:1. Prior medical necessity review experience preferredCORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.1. Evaluates the requested service to determine medical necessity, utilizing payers' criteria and industry standard clinical guidelines2. Review documentation in medical record that support the clinical picture/severity of illness/complexity of the patient care rendered to the patient.3. Uses clinical knowledge to identify potential clarifications of the record4. Assures effective communication of medical necessity to the applicable payer5. Responsible for staying up to date on payer clinical guidelines and authorization requirements6. Perform a determination if the preservice denial requires appeal or a peer-to-peer review7. Research and prepare appeal files in response to preservice clinical denials.8. Resolve clinical denials, which include researching and reviewing payer guidelines, writing, and submitting appeals with supporting documentation if required9. Analysis of clinical denials including identification of root cause to provide feedback to the physicians and or clinical departments10. Track and trend denials issues for escalation to leadership to assist with process improvement11. Actively participates in process improvement initiatives, working with a variety of departments and multidisciplinary staff.12. Effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment13. Consistently demonstrate ability to serve as a role model and change agent by promoting the concept of teamwork and the revenue cycle process continuum of high performing teamsPHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.1. Ability to sit for long periods of time.2. Ability to lift, push or pull approximately 25-80 pounds.3. Visual acuity must be within normal range4. Must have manual dexterity to operate keyboards, fax machines, telephones, and other business equipmentWORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.1. Standard office environmentSKILLS AND ABILITIES:1. Extensive knowledge of medical terminology, anatomy and pathophysiology, pharmacology and ancillary test results2. Proficient understanding of medical coding systems effecting the adjudication of claims payment. These include ICD-10,CPT,HCPCS,DRG,APG,APC,and revenue code3. Knowledge of the managed care industry including payer structures, administrative rules, and government payers.4. Demonstrates critical thinking skills, able to assess, evaluate, and teach5. Self-motivated and able to work independently without close supervision6. Ability to develop and maintain professional relationships to foster positive outcomes and collaboration.Additional Job Description:Scheduled Weekly Hours:40Shift:Exempt/Non-Exempt:United States of America (Exempt)Company:SYSTEM West Virginia University Health SystemCost Center:536 SYSTEM Hospital Authorization Unit