RN-Order/Medical Review

Job Summary Coordinates precertification/authorization services for patients across the continuum of care, promoting quality care, and effective utilization of resources. Provides leadership when dealing with patient preauthorization functions, including inpatient and outpatient services. Coordinates efforts between departments to ensure accurate precertification, resulting in timely billing of claims. Some overtime and call back may be required. Reports to the Director of CPAC. Performs other duties as assigned. Job Responsibilities Job Responsibilities • Assesses and evaluates clinical and financial information available and recommends the most appropriate delivery of services, including level of care in order to optimize resource consumption and reimbursement. • Precertifies patient care services that require precertification, in a timely, efficient manner, in order to optimize reimbursement for the patient as well as health care providers. • Communicates recommendations, clinical information, and fiscal information to appropriate internal and external customers in order to facilitate optimal delivery of services and customer satisfaction. • Reviews orders for accuracy and medical necessity to facilitate delivery of services and appropriate reimbursement. • Addresses issues identified with retrospective reviews for all payers. • All outpatient procedures will be timely precerted when applicable. • Works to improve the QI/PI process. • Assumes responsibility for personal growth and development by attendance and / or participation in inservices and continuing education programs. • Completes assigned goals.

Experience Description Minimum Required Preferred/Desired 3 years of clinical experience. Prefer experience in utilization/case management. Education Description Minimum Required Preferred/Desired Training Description Minimum Required Preferred/Desired Special Skills Description Minimum Required Preferred/Desired Advanced communication, conflict management, organizational and planning skills; advanced computer literacy skills. Prefer certification in CPHQ, CCM, ACM Licensure Description Minimum Required Preferred/Desired RN CCM;ACM