As a part of the Tenet and Catholic Health Initiatives family, Conifer Health Solutions is a leading healthcare business process management services provider working to improve operational performance to our clients so they can support financial improvement, enhance the patient experience, and drive value-based performance. Through our revenue cycle management, patient communications, and value-based care solutions, we empower healthcare decision makers—hospitals, health systems, physicians, self-insured employers, and payers—to better connect every point of care and wellness management. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
Conifer Health Solutions is currently hiring for an RN Retro Auth Nurse at ULH.
The Revenue Cycle Management Clinician for the Retro-Authorization Solution is responsible for: All clinical retro-authorization activities associated with patients financially cleared through the Patient Access Support Unit (PASU) and/or the Center for Patient Access Services (CPAS); Coordinating with ordering physicians and/or facility staff to secure the necessary prior payment authorization utilizing applicable payer criteria.
Performs retro-service authorization reviews to obtain payment authorization for both inpatient and outpatient services. Succinctly abstracts fact based clinical information to support retro-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.
Collaborate with and engage internal and external customers, such as facility patient access and physician offices, in opportunities for retrovention of future disputes; identifies potential process gaps and recommends sound solutions to CAS leadership. This includes follow up with the payer’s when a response is not obtained within 30 days by phone, email or fax.
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 contributes to successful implementation of all the above.
KNOWLEDGE, SKILLS, ABILITIES
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 retro-authorization guidelines and applicable regulatory processes related to the retro-authorization process
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).
- Minimum of 1-2 years as a pre-authorization, utilization review nurse and/or clinical team lead/supervisor in a payer or acute care setting;preferably medical-surgical or critical care/ED or equivalent healthcare experience.
CERTIFICATES, LICENSES, REGISTRATIONS
- Current, valid RN licensure
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 retro-service medical necessity reviews
Conifer - Louisville, KY