HCA, Hospital Corporation of America PreCertification Nurse LPN in Houston, Texas
Job Summary – Th e Pre- Certification Nurse will review all post discharge and or prebill accounts that do not have an authorization on file. Daily review of all LOS versus days authorized variances, and/or other account discrepancies identified that will result in the account being denied by the payer and that require additional clinical expertise. Communicates with third party payers to resolve discrepancies prior to billing and is responsible for accurately and concisely documenting all communications and actions that have occurred for the account in accordance with policies and procedures. Ensures that escalation for medical review request and/or denial activities to management team occur on a timely basis to escalate reimbursement and reduce further delays and or denials of claims.
S up e r v is o r – CIV Manager
S up e r v is e s – N / A
F un c t i on a l areas:
· O b tai n authorizations for post discharge, prebill accounts
· P erform re-certification for additional days on post discharge, prebill accounts
· eRequest/ Passport queues as determined during program implementation
D u t i e s (included but not limited to):
· Work retro Medicaid and prebill accounts efficiently and effectively obtaining authorizations for entire length of stay.
· Ev al u at es clinical documentation on multiple patient accounts and escalates issues through the established chain of command
· P erform accurate and timely documentation of all review activities based on policy and procedure
· D emonstrates 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
· R eport insurance denial trends identified during daily operational assignments
· Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed
· D emonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; m on it o r s self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives.
· Communicates effectively and professionally with physicians, hospital staff, and outside agencies
· A dh ere to all policies and procedures, including, attendance, phone and internet usage, break utilization, etc.
· Pa r ti c i p at e in education and training as needed
· E stablish and maintain relationships with all customers
· S eeks assistance from immediate supervisor when in situations which are unclear or ambiguous
· A dh eres to established policy and procedure and standards of care; escalates issues through the established Chain of Command timely
· D emonstrates commitment to teamwork and cooperation
· P r a c ti c e and adhere to the “Code of Conduct” philosophy and “Mission and Value Statement”
· O t h er duties as assigned
Knowledge, Skills & Abilities
· C ustomer Orientation – establishes and maintains long term customer relationships, building trust and respect by consistently meeting and exceeding expectations
· C ommunication - communicates professionally, clearly and concisely
· I nterpersonal skills – a b ilit y to establish and maintain collaborative and effective working relationships
· P C Skills – demonstrates advanced proficiency in Microsoft Office applications and others data mining software
· P olicies & Procedures - d emonstrates knowledge and understanding of organizational policies, procedures and systems
· B a s i c 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
· Cli nical skills – a b ilit y 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.
E D U C ATION
· A ssociate’s Degree or higher preferred
EX P E R I E N C E · Utilization Review, appeals, denials, managed care contracting, experienced preferred
C E R T I F I C A T E/ LICENSE – R N or LPN/LVN with current state licensure
Title: PreCertification Nurse LPN
Location: Texas-Houston-Shared Services - Houston
Requisition ID: 08948-125321