- The Clinical Reviewer assists with data collection, entry and generation of reports; coordinates communication between Patient Financial Services, Third party Payers, patients, and physicians; and performs certifications, authorizations, concurrent reviews, and appeals. The clinical reviewer will be responsible for reviewing inpatient and observation patients and performing certifications/authorizations for Medicare, Medicaid, Commercial, and Medicare HMO third party payers.
- Performs pre-certification, concurrent, retrospective and appeal review in an accurate and timely manner to assure reimbursement for Phelps Health.
- Acts as liaison between Patient Financial Service members and Care Management team.
- Works cooperatively with physician offices, communicating necessary information to assure reimbursements.
- Assists the Care Managers in visiting patients to check on discharge needs.
- Assists the Care Managers in referral calls for pre & post hospital care.
- Assists with communicating discharge-planning information to Third Party Payors and care providers.
- Completes appeals, back certifications, and retrospective reviews for the Denial, Prevention and Recovery department.
- Works under pressure and pays close attention to detail.
- Communicates clearly and effectively with a wide variety of individuals.
- Graduate of an approved practical nursing program or an equivalent combination of education and experience.
- At least two (2) years clinical experience in Utilization Management, Social Services, and/or Quality Management required. Experience working with third party payers is preferred.
- None required
- Considerable mental concentration required. Lifting up to 35 lbs., turning activities and nearly constant walking required. Standing, turning, carrying, pushing, pulling, stooping, crouching, twisting, and reaching.
- Frequent exposure to infectious disease and hostile persons at times. Frequent exposure to communicable disease via blood and other body fluids. Minimal physical discomfort.
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