PAM Health Rehabilitation Hospital of Kyle
Clinical Authorization Specialist | PAM Health Corporate
PAM Health Rehabilitation Hospital of Kyle - Plano, Texas, United States, 75023
Work at PAM Health Rehabilitation Hospital of Kyle
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Overview
Clinical Authorization Specialist
The Clinical Authorization Specialist is responsible for managing Commercial and Medicare Advantage admission authorizations by conducting a comprehensive analytic review of clinical documentation to determine if a patient is clinically appropriate for admission and the best course of action to obtain authorization from the payer. The Clinical Authorization Specialist will write sound, compelling, factual argument for the purpose of admission and/or to overturn a denial received from a payor for admission. Some things that our hospital can offer YOU as a full-time employee: Medical Benefits: EPO/HDHP/HSA options, including prescription coverage, Rx 'n Go, and Teladoc Comprehensive dental and vision benefits Employee Assistance Program, including counseling, legal, and financial service Flexible spending (FSA) and health savings (HSA) accounts Life and Disability insurance benefits Education/In-Service Opportunities including continuing education and tuition assistance Supplemental benefits: Accident, critical illness, cancer, pet, and identity theft protection insurance options Auto, Home, Cell Phone, and Gym Membership discount offerings Personal Travel Discounts Employee Bonus Referral Program 401(k) plans and discretionary employer match Generous Paid Benefit Time Responsibilities
Reviews patient medical records and utilizes clinical and regulatory knowledge and skills as well as has knowledge of payor requirements to determine the appropriateness of the admission. Utilize pre-existing criteria, other resources, and clinical evidence to develop sound and well-supported admission arguments. Prepares convincing arguments using pre-existing criteria sets and/or clinical evidence from existing clinical references and/or regulatory arguments and prepares requests to the payor in an effort to obtain admission authorization or overturn an initial denial in a professional and concise manner. Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Prepares feedback for summaries of appeal activities by hospital to be included in the Monthly Operations Reports. Has the ability to proficiently read, understand, and communicate in writing abstract information from patient medical records in a professional manner. Demonstrates excellent written communication. Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; and presents numerical data effectively. Ensures compliance with HIPAA regulations, including confidentiality, as required. Maintains the highest level of customer service via courtesy, compassion, and positive communication. Promotes the Mission and Vision of Post Acute Medical within the work environment and the community. Respects dignity and confidentiality by adherence to all applicable policies and procedures. Qualifications
Education and Training:
Bachelors or Associates degree in nursing preferred. Knowledge in the area of LTAC and IRF Criteria including: Medicare, InterQual and Milliman are preferred. Currently licensed as an RN, preferred. Experience:
Five years (5) experience as a clinical nurse in an acute care setting. In addition, having at least two years of experience in appeals, case management, discharge planning and/or utilization review is preferred.
The Clinical Authorization Specialist is responsible for managing Commercial and Medicare Advantage admission authorizations by conducting a comprehensive analytic review of clinical documentation to determine if a patient is clinically appropriate for admission and the best course of action to obtain authorization from the payer. The Clinical Authorization Specialist will write sound, compelling, factual argument for the purpose of admission and/or to overturn a denial received from a payor for admission. Some things that our hospital can offer YOU as a full-time employee: Medical Benefits: EPO/HDHP/HSA options, including prescription coverage, Rx 'n Go, and Teladoc Comprehensive dental and vision benefits Employee Assistance Program, including counseling, legal, and financial service Flexible spending (FSA) and health savings (HSA) accounts Life and Disability insurance benefits Education/In-Service Opportunities including continuing education and tuition assistance Supplemental benefits: Accident, critical illness, cancer, pet, and identity theft protection insurance options Auto, Home, Cell Phone, and Gym Membership discount offerings Personal Travel Discounts Employee Bonus Referral Program 401(k) plans and discretionary employer match Generous Paid Benefit Time Responsibilities
Reviews patient medical records and utilizes clinical and regulatory knowledge and skills as well as has knowledge of payor requirements to determine the appropriateness of the admission. Utilize pre-existing criteria, other resources, and clinical evidence to develop sound and well-supported admission arguments. Prepares convincing arguments using pre-existing criteria sets and/or clinical evidence from existing clinical references and/or regulatory arguments and prepares requests to the payor in an effort to obtain admission authorization or overturn an initial denial in a professional and concise manner. Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Prepares feedback for summaries of appeal activities by hospital to be included in the Monthly Operations Reports. Has the ability to proficiently read, understand, and communicate in writing abstract information from patient medical records in a professional manner. Demonstrates excellent written communication. Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; and presents numerical data effectively. Ensures compliance with HIPAA regulations, including confidentiality, as required. Maintains the highest level of customer service via courtesy, compassion, and positive communication. Promotes the Mission and Vision of Post Acute Medical within the work environment and the community. Respects dignity and confidentiality by adherence to all applicable policies and procedures. Qualifications
Education and Training:
Bachelors or Associates degree in nursing preferred. Knowledge in the area of LTAC and IRF Criteria including: Medicare, InterQual and Milliman are preferred. Currently licensed as an RN, preferred. Experience:
Five years (5) experience as a clinical nurse in an acute care setting. In addition, having at least two years of experience in appeals, case management, discharge planning and/or utilization review is preferred.