El Camino Health is committed to hiring, retaining and growing the best and brightest professionals who will carry our mission and vision forward. We are proud of our reputation in the community: One built on compassion, innovation, collaboration and delivering high-quality care. Come join the team that makes this happen.
Applicants MUST apply for position(s) by submitting a separate application for each individual job posting number they are interested in being considered for.
FTE: 1
Scheduled Bi-Weekly Hours: 80
Work Shift: Day: 8 hours
Job Description:
The Clinical Utilization Review and Appeals Coordinator combines clinical, business and regulatory knowledge and skill to reduce financial risk and exposure caused by concurrent and retrospective denial of payment for services provided.
Reviews and validates admission status of surgical admissions, verifies procedure against the Inpatient Only List and Inter-Qual Criteria, educates Physicians and facilitates obtaining the correct admission status, ensures that the appropriate notification letters are issued, reviews concurrent denials and provides insurance reviews, serves as an Inter-Qual resource to staff, provides oversight and compliance of the Observation status process, ensures compliance with the 2-midnight rule.
Pursues, analyzes and remains up to date on data regarding all medical necessity denials. Collaborates with physicians, case managers, Hospital Billing Office staff and payers to appeal denials. Insures a functional denial appeals process, including measuring denial and appeal activity, monitoring for patterns and trends, and reporting the outcomes of these activities as requested.
Serves as the central point person for all commercial and government claim recovery activities providing efficient management of work flow related to MediCal, commercial denial/appeal and Recovery Audit activities. Provides guidance, support and oversight to ensure effective management of the audit response process. Facilitates all aspects of the denial/appeal process which include maintaining database, tracking and trending denials, and reporting process outcomes.
Qualifications:
Bachelor of Science in Nursing
Five (5) years' experience in hospital admission appeals, case management, or clinical documentation improvement.
Experience with program development and strong working knowledge of federal government regulations with specific focus on Medicare and Medicaid reimbursement.
Proficient in database management.
Familiar with reviewing procedural documentation areas in electronic health record.
Highly collaborative and able to work cohesively in a dynamic team environment; strong interpersonal and professional skills.
Strong data processing and analytical skills, accompanied by strong critical thinking skills and an aptitude for conducting thorough research.
License/Certification/Registration Requirements:
Current registration in the State of California as a Registered Nurse.
Salary Range: $70.84 - $106.26 USD Hourly
The Physical Requirements and Working Conditions of this job are available. El Camino Health will provide reasonable accommodations to qualified individuals with a disability if that will allow them to perform the essential functions of a job unless doing so creates an undue hardship for the hospital, or causes a direct threat to these individuals or others in the workplace which cannot be eliminated by reasonable accommodation.
Sedentary Work - Duties performed mostly while sitting; walking and standing at times. Occasionally lift or carry up to 10 lbs. Uses hands and fingers.
An Equal Opportunity Employer:
El Camino Health seeks and values a diverse workforce. The organization is an equal opportunity employer and makes employment decisions on the basis of qualifications and competencies. El Camino Health prohibits discrimination in employment based on race, ancestry, national origin, color, sex, sexual orientation, gender identity, religion, disability, marital status, age, medical condition or any other status protected by law. In addition to state and federal law, El Camino Health also follows all applicable fair and equitable employment policies from the County of Santa Clara.
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