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Clinical Pre-Service Nurse Coordinator
2 months ago
The Clinical Pre-Service Nurse Coordinator plays a critical role in ensuring timely and accurate pre-service reviews, securing escalated insurance authorizations, and coordinating with Patient Access, Mid-Revenue Cycle, and Patient Business Service (PBS) to identify opportunities for revenue optimization.
Key Responsibilities- Works closely with Physician Providers to ensure that proposed intensity of service aligns with severity of illness and accurately documented to support level of care determinations and required authorizations.
- Investigates denials and root causes, tracks, and reports trends to remediate issues and assist with internal process improvement.
- Leverages clinical knowledge and standard procedures to ensure timely attention to denials as requested by PBS and assists in the research and application of regulatory policies to support administrative appeals.
- Communicates pertinent clinical information to Physicians, Medical Directors, and CFO, as indicated, regarding evaluation of medical appropriateness and/or payer determinations.
- Understands clinically complex medical situations and communicates appropriately with insurers as needed.
- Maintains a working knowledge of applicable Federal, State, and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
- Utilizes working knowledge of basic coding guidelines for medical necessity and insurance authorization escalations and/or denials.
- Awareness of how to navigate payer websites to occasionally validate insurance eligibility and authorizations.
- Familiarity with the construction of professional appeals in response to denied claims.
- PA Registered Nurse or Licensed Vocational Nurse/Licensed Practical Nurse and graduate of an accredited school of nursing, plus at least two (2) years of nursing experience.
- Minimum two (2) years of pre-certification/prior approval clinical denial unit management experience.
- Demonstrated knowledge of patient access, revenue cycle, and denial management functions. Certification and/or membership in AAPC, AHIMA, HFMA, AAHAM, NAHAM strongly preferred.
- Demonstrates an understanding of technical and clinical denials areas, such as: medical necessity, eligibility issues, no authorization. Working knowledge of medical terminology, and medical record coding experience (ICD-9, CPT, HCPCS) are highly desirable.
- Working knowledge of Epic Prelude and Resolute, including associated work queues is preferred.
- Strong organizational, task prioritization, resource management skills.
- Excellent written and oral communication & presentation skills.
- May be require travel up to 10% between locations within the Trinity Mid-Atlantic Region.
- Medical, Dental, & Vision Coverage
- Retirement Savings Program
- Paid Time Off
- Tuition Reimbursement
- Free Parking
- And more
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.
