Description

JOB SUMMARY

Responsible for providing specialized clinical review/appeal training via instructor- led remote training classes. Additionally, this individual develops quality reviews for the CRC and serves as the subject matter expert in the field of payer policy guidelines, bulletins, and the revenue cycle dispute process.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

Provides all new CRC employees with education on applications which have patient information. These include but are not limited to Cerner, HPF, Allscripts, MIDAS, Med Assets, & Code Correct. The training provided will be specific to clinical review and the rational supporting the appeal for medical necessity, lack of authorization, and other types of disputes.Provides all current CRC nurses with ongoing clinical training on current CRC processes which include but are not limited to: McKesson InterQual® reviews, the research and application of CMS guidelines, the research and application of commercial payer policies, and the appropriate submission of an appeal to an Independent Review Organization..Assists management in the development of the peer review audit tools as well as the development of the quality program implemented by the CRC. Examples include but are not limited to: monthly quality reviews, quarterly Inter Rater Reliability Reviews,(IRR) and the yearly InterQual® exam.Functions as a performance consultant collaborating with operation managers to perform needs assessment and recommend training solutions.Completes monthly quality reviews on all new employees for 1 year as directed by CRC Operations Managers/DirectorsServes as a subject matter expert on policy or guideline interpretation/definition. This individual provides clinical summaries for clients as needed to assist with facility level education. This includes but is not limited to: writing a clinical summary for a case review in which the facility/client disagrees with the CRC dispute determination, the FDA’s recommendations on the appropriate use of experimental/investigational items, such as bone grafts, medications, implants etc…Assists with the review of special projects as assigned in collaboration with CRC staff to include the completion of the executive summary as needed.Other related duties as assigned.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Thorough knowledge of requirements for all payer types as they pertain to utilization review for acute inpatient and ambulatory care patients; specifically the clinical pre & retro authorization processes, retro clinical denials management, and government audit services: Federal and state regulatory and compliance requirementsClient facility payer contractual requirements.Thorough knowledge of Medical Necessity Screening Criteria process including McKesson’s InterQual® Criteria products and others, such as Milliman Care Guidelines® as applicable to the client facility.Thorough knowledge of Medicare coverage determinations process (NCDs, LCDs) and the appeals process.Experience with multiple CM and health information system technology solutions (inpatient and outpatient).Excellent organizational skills for the execution of leading practices.Experience with supplier governance and management.Must be able to maintain confidentiality regarding patient/employee/facility/corporate information 100% of time.Understanding of healthcare and revenue cycle services as it relates to denials.As a skilled facilitator this individual must consistently demonstrate effective questioning techniques and the ability to engage students and transfer knowledge.Establish and maintain collaborative relationships with CRC operations managers and CRC Senior Director to meet business objectives.Working knowledge of training tools and various multimedia technology.Strong communication skills, both verbal and written. Ability to work with minimal supervision, self-starter, and demonstrates initiative. Flexible and innovative; highly adaptable to dynamic business environment; catalyst for change.High engagement; supportive of leadership and role model for Conifer values and guiding behaviors.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

EDUCATION / EXPERIENCE

Include minimum education, technical training, and/or experience preferred to perform the job.

Nursing degree required, preferably BSN3 - 5 years’ experience in training or leadership position preferredRevenue cycle experience preferred

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Ability to lift 25-35 lbs., due to travel requirementsAbility to communicate to large groups verbally and through various media

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Telecommuting EnvironmentOffice Work Environment

OTHER

May require travel – can vary from approximately 25% to 75%

As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities, and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost, and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Compensation and Benefit Information

Compensation

Pay: $64,168.00 - $96,262.00 annually. Compensation depends on location, qualifications, and experience. Management level positions may be eligible for sign-on and relocation bonuses.

Benefits

Conifer offers the following benefits, subject to employment status:

Medical, dental, vision, disability, life, and business travel insurancePaid time off (vacation & sick leave) – min of 12 days per year, accrued accrue at a rate of approximately 1.84 hours per 40 hours worked.401k with up to 6% employer match10 paid holidays per yearHealth savings accounts, healthcare & dependent flexible spending accountsEmployee Assistance program, Employee discount programVoluntary benefits include pet insurance, legal insurance, accident and critical illness insurance, long term care, elder & childcare, AD&D, auto & home insurance.For Colorado employees, Conifer offers paid leave in accordance with Colorado’s Healthy Families and Workplaces Act.2403030323