BASIC PURPOSE OF THE JOB

Performs concurrent and retrospective appeals for patient account denials at East Tennessee Children's Hospital.

REPORTS TO

• Director-Health Information Management

JOB REQUIREMENTS

Supervisory Responsibilities: Yes

Minimum Education: Associates Degree Required; Bachelors preferred

Degree: Degree in Nursing or Health information Administration

License/Certification Required: RN Licensure in the State of Tennessee OR RHIA required

Minimum Work Experience: 5 or more years Utilization Review experience

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Strong computer skills. Ability to work priorities and meet specific objectives under time constraints. Strong interpersonal skills. Ability to interact with persons of varying backgrounds and education level. Strong ability to effectively interact with all healthcare providers and managed care organizations. Strong English grammar and spelling skills.

DUTIES AND RESPONSIBILITIES

• Reviews appeals received from the Utilization Management Coordinators. Concurrent Reviews -  submits patient information to Executive Health Resources (E-HR) for a peer to peer phone call. Retrospective Reviews - processes the appeals package and submits to E-HR via mail or fax
• Maintains an accurate and up-to-date spreadsheet for appeals including concurrent, retrospective, external and second level reviews.
• Processes second level and external appeals if initial appeal is denied.
• Enters appeal and denial information accurately into Meditech Electronic Health Record (EHR)
• Prepares monthly denial/appeal data for the Utilization Management Committee.
• Assists utilization management precertification processes during high volume months and during staff shortages.
• Actively participates in the Utilization Management Committee. Assists outside agencies in a courteous manner. Demonstrates respect and regard for the dignity of all patients, families, visitors and fellow employees to ensure a professional, responsible, and courteous environment. Consults, interacts with and assists physicians, physician advisors, practitioners, both internal and external, in a courteous and professional manner.
• Continuously displays a positive attitude within the department and across departmental lines to contribute to the overall customer service program in place at the hospital.
• Assists interdepartmental and other hospital co-workers as needed in a courteous and professional manner.
• Communicates with insurance and/or other outside representatives in a courteous and professional manner.
• Willingly accepts any other assignment that may be requested.
• Processes and monitors all appeals for inpatient, observation and same day surgery accounts.
• Utilizes hospital resources and time respectfully and accountably.

PHYSICAL REQUIREMENTS

• Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.
• Heavy lifting, pushing, and pulling is required up to 50 lbs occasionally, 20-30 lbs frequently, and 10lbs constantly to move objects of up to 150 lbs. Sudden emergency situations have the potential for exposure to lifting or moving of up to 150 lbs. Frequent bending, walking, sitting squatting, reaching, and standing are required. Keyboard/computer use and/or repetitive motions may be required.

Come work where you can make a difference everyday.