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Supervisor, Centralized Pre-Certification (REMOTE) Job

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Date: Jun 17, 2022

Location: Memphis, TN, US

Company: Methodist Le Bonheur Healthcare

Summary

Responsible for supervising and organizing the work activities of the Authorization Specialists within the Centralized Services Authorizations & Denials Management Department within the MLH system. Serves as a liaison between ordering and referring physicians, insurors, patient financial services, case management, HIM, PAS, surgery and diagnostic departments, and patients while evaluating clinical criteria to assure that pre-authorizations are obtained timely and correctly and assure that medical necessity requirements are met that secure successful payment for procedure(s) performed within the MLH system. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

Education/Experience/Licensure

  Education/Formal Training Work Experience Licensure/Credential
Required: Graduate from an accredited nursing program.
  • Minimum of five (5) years of clinical nursing, precertification and authorization, case management or related work experience required.
  • Experience working with pre-certification and/or CPT medical codes.
Licensed as RN or LPN to practice in the state where work is performed.
Preferred: N/A Lead or supervisory experience preferred. N/A
Substitutions Allowed: In lieu of degree, the candidate must have an Associate’s degree with nine years of clinical nursing, precertification and authorization, or case management experience. N/A N/A

 

Knowledge/Skills/Abilities

  • Demonstrated leadership abilities, strong human relations skills, judgment and supervisory skills in organizing work, assigning staff and making exceptions to policy.  
  • Knowledge of medical terminology and procedures based on clinical cerficiation and work experience.
  • Knowledge of the legal and technical aspects of admitting, third party insurance and scope of responsibility in treating indigent patients.
  • Knowledge of CPT, ICD-10 and HCPCS coding guidelines.
  • Extensive knowledge in insurance coverage practices, terminology, and requirements for referrals and authorization/pre-certification used by third party payers, Medicare, and secondary payer rules. 
  • Ability to plan, prioritize and schedule tasks and to maintain control of own work flow as well as that of the department.
  • Positive working relationship and excellent interpersonal relationship skills in working with physicians required.
  • Strong attention to detail and critical thinking skills.  Ability to make decisions based on clinical knowledge/practices.
  • Experience with a computerized healthcare information system required. Familiarity with fundamental Microsoft word software.  (Proficient in Microsoft Office such as Word and Excel.)  
  • Excellent verbal and written communication skills.
     

Key Job Responsibilities

  • Supervises day to day departmental operations and processes of the Centralized Pre-Authorization & Denials Management department. Provides guidance, support and direction to the department and staff.
  • Plans and schedules work ensuring distribution of assignments and adequate staffing based on workload and productivity standards.  Monitors Associates performance and clarifies work expectations, assists with goal setting, and promotes cooperation among individuals and groups. 
  • Assists staff with the understanding and implementation of policies and procedures to increase the overall efficiency of the department.
  • Monitors, measures & develops tools by which the Centralized teams will support overall system and departmental goals.  Encourages innovation within the team which meet or exceed performance against goals (KPIs – Pre-Certification, Denials Management).
  • Exhibits creativity in investigating best practices which contribute to organizational & individual objectives.  Targets important areas & develops solutions that address problematic work issues.
  • Utilizes electronic tools to understand how claims were paid or denied that include Bridge, Stockamp, Xactimed & all payor websites.  Assists with specialty audits as needed to research service charge reimbursement, patient billing complaints & billing impact analysis with trending.
  • Actively monitors and oversees the quantity of diagnostic and surgical procedures to ensure efficiency of precertification. Ensures priority, development & implementation of daily strategy for patient volumes.
  • Works with associates in complex pre-certification cases, ensuring protocols are followed and reimbursements are maximized.
  • Works with payers to resolve technical problems and keep up with communications to eduate the team on changes that may affect reimbursement and precerts.
  • Educates all pertinent stakeholders on improvement opportunity trends & solicits collaboration & vested interest in the resolution of reimbursement issues & customer service barriers across multi-disciplinary teams in all levels of the organization.
  • Collaborates with others to engineer efficient & reliable data extraction methods, leverage technology, streamline/automate processes & ensure effective use of clinical information technology.
  • Establishes a good working relationship with physicians, physician office staff, patients, and other members of the healthcare team.  Develops trust & credibility with the customer, both internal & external. 
  • Communicates educational tools & program throughout the MLH system & with physician office staff regarding Centralized processes, policies & procedures.  Ensures that the Centralized Services Pre-Authorization & Denials Management Department remains compliant with state, federal and other regulatory agencies while providing superior service to facility departments, physicians and office staff and all internal & external customers in a fiscally responsible manner.  Monitors Payor bulletins for changes in pertinent medical policy and/or prior authorization requirement changes.  Communicates pertinent changes with the distribution of the bulletins to all areas which require the information.
  • Participates in the preparation of the capital budgets for assigned area(s), monitors and authorizes expenditures within budget limits. Assists in the development and implementation of capital budget and plans to control costs and improve department operations.
     

Physical Requirements

  • The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
  • Must have good balance and coordination.
  • The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
  • The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
  • The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative.


Nearest Major Market: Memphis

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