Cleveland Clinic Hiring for Coordinator Resource Center at Akron, Ohio Full Time

• Ensures the appeal process flow and meets appeal deadlines
• Prepares appeal letters using by researching and collecting data and using accepted clinical guidelines and best practices; e.g., Interqual or Millimen Care Guidelines (MCG)
• Obtains and evaluates medical records for inpatient admissions to determine if required documentation is present for appeal purposes
• Collaborates with appropriate physicians, ancillary departments
• Coordinates with denial management team to analyze patterns and trends and identify strategies for solution.
• Receive, process and scan all denial correspondence appropriately, according to established denial/appeal processes
• Constructs appeal letters for RAC denials- 1st level, 2nd level and ALJ level
• Works with CDI team, physician offices, other treating facilities and ancillary hospital clinicians to gather records and supportive literature/standards/guidelines to support RAC appeal at all levels
• Interacts and works collaboratively with denial management to secure correct documentation and clarify RAC related issues
• Generates and maintains internal reports of RAC activity and associated deadlines
• Identifies trends with denials providing communication and education to all necessary parties
• Works collaboratively with cardiologists office to obtain precertification for inpatient cardiac procedures: PVAI, ICD, Drug Loading, CRT-D, Insertion/Extraction of leads and documents approval appropriately
• Supports physician peer to peer appeal process by researching and referring to the department Medical Director, denied active inpatient claims requiring physician review with payor, in compliance with department procedures and follows up as indicated
• Answers payors? questions and provides additional clinical information when requested to preempt denials
• Monitors inpatient and outpatient procedures that require Medicaid (Permedion) approval including (but not limited to): Cardiac Catheterizations, EGDs ?inpatient, Interventional Radiology procedures, Chemotherapy Administration to inpatients, Surgical Procedures
• Coordinates with Care Managers and obtains Prior Author ization for Medicaid procedures by utilizing the MITS system, obtaining clinical information and working with physician’s offices and Permedion staff when obtaining prior authorization for procedures and denial issues
• Completes retrospective clinical reviews as requested by third party payors, for patients discharged over weekend and ensures appropriate billing status (Inpatient v.STO) in billing/registration system
• Reviews all admissions/discharges to ensure elective vs. urgent admissions are designated accurately in HIS to facilitate proper billing.
• Provides ongoing communication, information, guidance, and support to Care Managers and Resource Center Reimbursement Specialists regarding payor specific questions as requested.
• Receives updates regarding third party contractual changes from the Managed Care Department and communicates the changes to the Reimbursement Specialist.
• Participates in the continuous quality improvement activities of the department and institution.
• Proficient in health system/department specific software- HIS, MIDAS, Med Assets, MITS, TEMPUS, AGMC Portal, 3M and Chart Maxx
• Understands and adheres to compliance of all payor guidelines
• Attends in-services, education sessions and department meetings as scheduled
• Ensure confidentiality of all patient accounts by following HIPAA guidelines
• Completes annual on-going competency requirements. Attends continuing education programs and completes mandatory training in order to maintain certification and licensure, department specific requirements and professional growth.
• Follow hospital and department policies and procedures with special attention to attendance and punctuality, confidentiality, dress code and display of ID badge and safety.
• Other duties as assigned

Education:

• BSN preferred.

Certifications:

• Current license in State of Ohio.

Complexity of Work:

• Excellent verbal and written communication skills.
• Strong interpersonal skills.
• Has working knowledge of ICD 9 Diagnosis and Procedure Codes as well as CPT Procedure Codes.

Work Experience:

• Three to five years of experience (UM case management and/or discharge planning experience preferred.) Strong computer skills.

Physical Requirements:

• Works in an environment where there is some discomfort due to dust, noise, temperature.
• Requires extensive walking, telephone use, bending, reaching, and lifting items weighing twenty pounds or less.
• Must be able to work well under pressure and maintain professional demeanor under adverse conditions.
• Extensive reading, writing, use of pagers, fax machines, computers, and copiers.
• Sedentary Work – Exerting up to 10 pounds of force occasionally (Occasionally: active or condition exists up to 1/3of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.

Personal Protective Equipment:

• Follows standard precautions using personal protective equipment as required