RC Pre-Authorization Clinician

Working Location: THOP Memorial Campus

Spanish Bilingual Required

JOB SUMMARY

The Revenue Cycle Management Clinician for the Pre-Authorization Solution is responsible for:

a) All clinical pre-authorization activities associated with patients financially cleared through the Patient Access Support Unit (PASU) and/or the Center for Patient Access Services (CPAS).

b) Coordinating with ordering physicians and/or facility staff to secure the necessary prior payment authorization utilizing applicable payer criteria.

Include the following. Others may be assigned.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Performs pre-service authorization reviews to obtain payment authorization for both inpatient and outpatient services.  Succinctly abstracts fact based clinical information to support pre-authorization utilizing applicable nationally recognized and payer-specific criteria; communicates timely the clinical information supporting the medical necessity of an ordered test/treatment/procedure/surgery as applicable to the patient’s health plan and documents the outcome of the task.
• Performs the following activities to support the effective operation of the organization’s quality management system.  A minimum of 2.5 % of time is spent carrying out the following responsibilities:  Participation in quality control audit process; participation in department projects and activities to improve overall Conifer and client scorecard metrics. provides feedback regarding improvement  opportunities for workflow &/or procedures; and the contributes to successful implementation of all the above.
• Demonstrates proficiency in the use of multiple electronic tools required by both Conifer and its clients.  
• Collaborate with and engage internal and external customers, such as facility patient access and physician offices, in opportunities for prevention of future disputes; identifies potential process gaps and recommends sound solutions to CAS leadership. 
• Other duties as assigned 

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to work independently and self-regulate in compliance with deadlines
• Proficiency in the application of applicable nationally  and payer authorization criteria
• Possesses excellent customer service skills that include written and verbal communication.
• Minimum Intermediate Microsoft Office (Excel and Word) skill
• Ability to critically think, problem solve and make independent decisions 
• Ability to interact intelligently and professionally with other clinical and non-clinical partners
• Ability to prioritize and manage multiple tasks with efficiency
• Advanced conflict resolution skills
• Ability to communicate effectively at all levels
• Ability to conduct research regarding payer pre-authorization guidelines and applicable regulatory processes related to the pre-authorization process

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment.  This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience required to perform the job.

• Must possess a valid nursing license (Registered or Practical/Vocational).  LPN or RN PREFERRED. 
• Minimum of 3-5 years as a pre-authorization or utilization review nurse in a payer or acute care setting; preferably medical-surgical or critical care/ED

CERTIFICATES, LICENSES, REGISTRATIONS

• Current, valid RN/LPN/LVN licensure
• Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) or Certified Case Manager (CCM) preferred 

PHYSICAL DEMANDS 

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.

• Ability to lift 15-20lbs 
• Ability to travel approximately 10% of the time; either to client &/or Conifer office sites
• Ability to sit and work at a computer for a prolonged period of time conducting pre-service medical necessity reviews

WORK 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.

• Characteristic of typical Call Center environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.

OTHER

• May require travel – approximately 10%
• Interaction with staff at client facilities such as and not limited to Patient Access, Case management, physicians and/or their office staff is a requirement.