Supports the revenue cycle by completing retrospective reviews to ensure medical necessity criteria is met. Assures enterprise activities conform to regulatory requirements and identifies trends, process opportunities to maximize reimbursement. Supports policy development and interdisciplinary education.
Payer Denial Management Nurse: Supports the denial and appeal process within the Payer Denial Management department. Coordinates denial appeal follow-up and analyzes provided clinical documentation, criteria application, physician advisor input, completes review of the medical record and formulates the appeal letter. Participates in the application of medical necessity review and utilizes criteria tool (MCG and/or InterQual). Ensures compliance standards are met with required elements and provides feedback to the management team. Relays physician, nursing and care manager documentation improvement opportunities to assist with appeal defense process.
RAC /Payer Audit Nurse: Supports denials, appeals, within the Payer Audit department. Conducts audit reviews to assure activities conform to regulatory requirements. Coordinates denial appeal follow-up; analyzes provided clinical documentation, criteria application outcome, physician advisor input, completes review of the medical record and formulates the appeal letter. Expert in the application of medical necessity review criteria tool (MCG and/or InterQual). Supports the development of performance improvement strategies in response to identified patterns and trends involving government payers.
Charge Capture Nurse: Supports the Observation charge capture process for the enterprise. Works with a multi-disciplinary team to evaluate and improve the charge capture process. Reviews the medical record for Observation cases to ensure accurate and timely billing of observation hours and appropriate charges. Utilizes the application of medical necessity review criteria tool (MCG and/or InterQual). Works cooperatively to review, evaluate and improve the charge capture process to establish an enterprise uniform process. Supports development of performance improvement strategies in response to identified patterns and trends.
Other duties as assigned.
Bachelor of Science in Nursing or Bachelor's degree in a related field preferred.
Licensed Registered Nurse (RN) in the state of Ohio, BSN preferred.
Professional certification as a Case Manager preferred.
Expertise with InterQual and Milliman disease management ideologies preferred.
COMPLEXITY OF WORK:
Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
Must be able to work in a stressful environment and take appropriate action.
Minimum 3-5 years Care Management or Utilization experience which would include acute med/surg experience required.
Expertise with InterQual and Milliman disease management ideologies is preferred.
In-depth familiarity with third party billing requirement and regulations, billing documentation requirements preferred. Understanding of CPT and HCPCS coding guidelines preferred.
Manual dexterity to operate office equipment.
Requires extended periods of standing, walking, sitting and carrying up to 10 pounds.
Normal or corrected vision and hearing to normal range.
PERSONAL PROTECTIVE EQUIPMENT:
Follows standard precautions using personal protective equipment as required.
The policy of Cleveland Clinic and its system hospitals (Cleveland Clinic) is to provide equal opportunity to all of our employees and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. Job offers will be rescinded for candidates for employment who test positive for nicotine. Candidates for employment who are impacted by Cleveland Clinic’s Smoking Policy will be permitted to reapply for open positions after 90 days. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic facility.
Cleveland Clinic is pleased to be an equal employment employer: Women/Minorities/Veterans/Individuals with Disabilities
Internal Number: 83055
About Cleveland Clinic
Cleveland Clinic is a nonprofit, multi specialty academic medical center integrating clinical and hospital care with research and education for better patient outcomes and experience. More than 3,900 staff physicians and researchers in 180 medical specialties provide services through 26 clinical and special expertise institutes. Cleveland Clinic comprises a main campus, 11 regional hospitals and more than 150 outpatient locations with 19 family health centers and three health and wellness centers in northern Ohio, as well as medical facilities in Florida, Nevada, Toronto and Abu Dhabi. Cleveland Clinic is currently ranked as one of the nation's top hospitals by U.S. News & World Report.