Typical Duties
- Analyzes the prior authorization denials report to identify reason for denials in detail including inaccurate and/or missing information in detail.
- Works closely with management to evaluate payer changes or other items that may impact reimbursement affected by prior authorization.
- Recognizes billing errors and when to submit a reconsideration request for payment with all appropriate documentation.
- Analyzes denial reports and recommend changes to workflow as appropriate with impacted departments on any deficiencies in workflow or system build.
- Reviews denials report for patterns related to repeated denials from a particular insurance carrier. Understands how to identify errors and works with contract staff to address.
- Ensure patients receive the services that require prior authorization from insurance carriers by addressing and rectifying rejected claims that require additional documentation and/or Peer to Peer Consultation.
- Collaborates with other departments to assist in obtaining prior authorizations.
- Completes data review and reports on metrics/trends of authorization denials.
- Maintains an audit trail of changes to authorization requirements to assist with root cause analysis and support cause for appeals.
- Develops and maintains a strong working relationship with hospital departments and referring physicians to collaborate in obtaining information needed for successful appeal/reversal of authorization denial.
- Maintains a current knowledge related to insurance changes and requirements for prior authorization.
- Gathers data, performs a detailed review, and submits a report based on findings, as directed.
- Attends and participates in meetings, as needed.
- Performs other duties as assigned by the Director of Pre-Patient Access.
- Licensed as a Registered Professional Nurse in the State of Illinois
- Two (2) years of nursing work experience
- One (1) year of work experience in Utilization Management/Prior Authorization in a physician group, insurance company or management services organization
- Prior experience identifying trends in prior authorization and denial prevention, i.e., incomplete coding, lack of documentation
- Care management or medical insurance experience
- Bachelor’s degree in nursing from an accredited college or university
- One (1) year experience with electronic medical records (EMR)
- Prior experience using InterQual or Milliman criteria sets
- Excellent verbal, written communication, and interpersonal skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
- Knowledge and proficiency with Microsoft applications and internet-based programs
- Strong interpersonal skills with the ability to establish strong working relationships
- Strong time management skills to prioritize assignments and meet the designated deadlines
- Ability to anticipate, recognize, and meet the needs of patients and families
- Ability to work in a team-based environment to accomplish goals and objectives
- Ability to demonstrate respect and sensitivity for cultural diversity in CCH work force and patient population
- Ability to critically think, problem solve and make independent decisions supporting the authorization process, including interactions with payer representative, physicians, and hospital case managers
- Competitive Salary
- Paid Time Off
- Health, Vision & Dental Insurance
- Health Savings Account (HSA)
- Flexible Spending Account (FSA)
- Short & Long Term Disability
- 401 (K) with company match
- Life Insurance
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What We Do
Keystone Advisors of Illinois, LLC. (Keystone) specializes in providing Staff Augmentation services in the areas of Financial Management, Program Management, and IT. Established in 2008, our principals have over 30 years’ experience in providing recruiting and Human Resources Services to the DLA and DOD prime contractors.
Keystone has a staff of 4 recruiters and 2 Account managers and our compensation, recruitment and retention policies are designed to attract and retain the best human resources available to assist our clients in meeting their mission critical needs. We currently have 40 people on staff on various positions around the CONUS.
Keystone maintains a proprietary database of over 500,000 potential resources in labor categories such as Program Managers, Financial Managers, and IT Personnel. In addition Keystone is a licensed CPA firm and has Primed Projects involving Program managers and Financial Managers, licensed CPAs, Certified Information Systems Auditors (CISAs), Accountants, IT Specialists and Program Managers who have deep experience in Federal financial statement preparation, Budget and Analyst. We have past performance in working on audit readiness projects with the Navy, Army, Defense Logistics Agency (DLA), and Defense Finance and Accounting Service (DFAS)
