RN-Order/Medical Review

Job Title

Job Info

Job Identification 44514

Job Category NURSING

Business Unit BMHCC System Services

Department Centralized Patient Access Center

Job Description

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

• Assess and evaluate clinical and financial information available and recommend the most appropriate delivery of services, including level of care in order to optimize resource consumption and reimbursement.
• Precertify 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.
• Communicate recommendations, clinical information, and fiscal information to appropriate internal and external customers in order to facilitate optimal delivery of services and customer satisfaction.
• Review orders for accuracy and medical necessity to facilitate delivery of services and appropriate reimbursement.
• Address issues identified with retrospective reviews for all payers.
• All outpatient procedures will be timely precerted when applicable.
• Work to improve the QI/PI process.
• Assume responsibility for personal growth and development by attendance and/or participation in inservices and continuing education programs.
• Complete 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