Clinical Review and Appeals Specialist
Life Care Centers of America
Cleveland, TN
Position Summary
- The Clinical Review and Appeals Specialist timely reviews audit requests and denied claims from all payors related to medical necessity, appropriate setting/status determination, authorizations, and appropriate length of stay. Ensures all audits and/or denied claims are accurately worked and appealed to obtain maximum reimbursement and minimize recoupment in accordance with all applicable laws, regulations, and Life Care standards.
- Reports to Director of Clinical Review and Appeals
Working Conditions
- Works in office setting as well as facility sites (e.g., division office, off-site venues, facilities)
- Subject to frequent interruptions
- Involved with patients, associates, visitors, government agencies/personnel, etc. under all conditions and circumstances
- Subject to hostile and emotionally upset patients, family members, etc.
- Works beyond normal working hours, on weekends and holidays, and in other positions temporarily as necessary
- Subject to falls, burns from equipment, odors, etc. during facility visits
Education, Experience, and Licensure/Certifications
- Must have Registered Nursing (RN) degree (RN) from an accredited college or university
- Must be currently licensed/registered in applicable state. Must maintain an active Registered Nursing (RN) license in good standing throughout employment
- Or must have minimum an Associate’s/Bachelor’s degree from accredited PT/PTA or OT/OTA program OR minimum Master’s degree from SLP program
- May have a certification in Healthcare and Quality Management (HCQM)
- Must have extensive knowledge of the RAI process, Medicare regulations, Quality Measures, and PDPM
- Must have experience in managing multiple people and facilities
- Certification in HealthCare Compliance (CHC) preferred
- Must have knowledge of the Quality Reporting Program
Specific Requirements
- Must be willing and able to travel, including air travel
- Must be proficient in Word, Excel, and e-mail
- Must have excellent verbal and written communication skills
- Must maintain a positive attitude and positive communication supporting Life Care goals and initiatives
- Must be able to follow directions of supervisor
- Must communicate and function productively with associates at the facility, regional, and division levels
- Must possess the ability to make independent decisions when circumstances warrant such action
- Must be knowledgeable of nursing practices and procedures as well as the laws, regulations, and guidelines governing nursing functions in the post-acute rehab and long-term care facility
- Must have the ability to implement and interpret the programs, goals, objectives, policies, and procedures of the Clinical Services department
- Must perform proficiently in all applicable competency areas (See position competencies for additional details)
- Maintains professional working relationships with all associates, vendors, etc
- Maintains confidentiality of all proprietary and/or confidential information
- Must understand and follow company policies including harassment and compliance procedures
- Displays integrity and professionalism by adhering to Life Care’s Code of Conduct and completes mandatory Code of Conduct and other appropriate compliance training
Essential Functions
- Must be able to effectively direct the management of clinical and/or rehabilitation denials in accordance with Federal guidelines and company benchmarks
- Must be able to implement a denial prevention program that focuses on documentation quality: manage denial process to achieve benchmarks
- Must be able to collect, review and analyze current audit data. Must be able to identify trends and initiate clinical quality improvement initiatives, focus on improving clinical quality indicators, outcomes, and financial metrics
- Must be able to oversee collection and utilization of operational and benchmarking data to recommend and set targets for improvement based on research of industry best practices and recommending process improvements
- Must be able to stay current with any reimbursement or MDS and Rehab updates and provide education opportunities when needed
- Must be able to provide education as needed regarding updates or changes to the CMS RAI Manual or Skilled Nursing Facility Regulations that impact reimbursement
- Must be able to serve as subject matter expert for appeals and denials and as a resource for clinical services team and provide education to promote reduction in denials
- Must be able to answer questions related to audits and appeals
- Must be able to develop tracking systems to provide accurate audit and denial data
- Must be able to document and log audit and appeal data timely
- Must be able to complete clinical review of appropriate pre- and post-claim denials.
- Must be able to prepare clinical discussions and appeal letters for appeal
- Must be able to ensure submission of appeals to the payors within allotted time frames to prevent fiscal penalties
- Must be able to assist clinical corporate with development of policies, procedures, education modules, and other training materials, related to coding, denials and accurate billing, when requested
- Must be able to complete compliance review to include researching and supporting questions related to Federal guidelines and state practice acts
- Must be able to serve as therapy liaison with Compliance, Medicare Claims and IT
- Must be able to serve as link between Therapy and Compliance related to coding issues and initiatives and ensures accurate ICD-10 and HCPC coding
- Must exhibit excellent customer service and a positive attitude
- Must be able to assist in the evacuation of patients
- Must demonstrate dependable, regular attendance
- Must be able to concentrate and use reasoning skills and good judgment
- Must be able to communicate and function productively within an interdisciplinary team
- Must be able to sit, stand, bend, lift, push, pull, stoop, walk, reach, and move intermittently during working hours
- Must be able to read, write, speak, and understand the English language
- Must be able to lift weight as deemed appropriate for the position
An Equal Opportunity Employer
Job Type: Full-time
Benefits:
- 401(k)
- Dental insurance
- Employee assistance program
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Ability to Commute:
- Cleveland, TN 37312 (Required)
Ability to Relocate:
- Cleveland, TN 37312: Relocate before starting work (Required)
Work Location: In person
