Medical Claims Review Manager jobs in Billings, MT

May be eligible for $3,000 sign on incentive
May be eligible for relocation assistance
May be eligible for tuition loan reimbursement

Under the direction of department leadership, the Utilization Review/ Management RN. This position is to conduct initial, concurrent, retrospective chart review for clinical financial resource utilization. Coordinates with healthcare team for optimal/efficient patient outcomes, while decreasing length of stay (LOS) and avoid delays and denied days. They are accountable for a designated patient caseload and provides intervention, and coordination to decrease avoidable denial of reimbursement. Specific functions within this role include: Screens pre-admission, admission process using established criteria for all points of entry. Facilitates communication between payers, review agencies, healthcare team. Identify delays in treatment or inappropriate utilization and serves as a resource. Coordinates communication with physicians. Identify opportunities for expedited appeals and collaborates resolve payer issues. Ensures/Maintains effective communication with Revenue Cycle Departments.

Essential Job Functions

•Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements.
•Maintains competency in all organizational, departmental, and outside agency requirements.
•The responsibilities of the UR case manager are listed below, in order of priority and intended to ensure effective prioritization of tasks.
•Priority 1: Reviews New Admissions, Observation and Outpatient Cases
•Prioritize reviews of all OBS and bedded Outpatients
•Communicate with attending physician to discuss case and obtain information not documented in record, when OBS cases do not meet payer criteria or OBS ≥ 24 hours
•Communicate with attending physician for OBS patients meeting medical necessity for inpatient level of care to obtain inpatient order
•Communicate with Case Manager to understand discharge plan and barriers to discharge on OBS and Outpatient in a Bed patients
•Participate in daily OBS call and communicate why patient is here, what we need from the team to get the patient to the next level of care, and expected discharge plan
•Ensure that admission review is completed on assigned units/worklist using payer MCG or CMS 2 Midnight Rule within 24 hours of admission
•Identify incomplete reviews from worklist
•Validate OBS orders daily for new admissions, within 24 hours
•Ensure order in chart coincides with the payer review, CMS 2 Midnight Rule, or payer authorization for status and level of care
•Priority 2: Performs Utilization Review (UR) Activities
•Completes concurrent Level of Care (LOC) & status reviews utilizing payer criteria to assure all days of hospitalization are covered/certified or meet CMS 2 Midnight Rule (as appropriate) at minimum of every 3 days or more frequently based on payer requirements
•Reviews observation patients at a minimum twice a day. Communicates with attending on medical plan and Case Manager on discharge plan to expedite progression to next level of care or discharge
•Discusses case with attending when payer authorization does not match status or level of care.
•Obtains information not documented in the EMR and requests documentation of medical necessity to support appropriate status (IP, OP, OBS) and level of care (Med-surg, SDU, ICU, etc.)
•If attending is unable to provide additional clinical information supporting status or LOC, escalate case to the physician advisor for second level review as early as possible and before leaving for the day
•Communicates to Case Manager any discrepancies on status or level of care based on medical necessity and/or payer authorization discrepancies
•Communicates to Case Manager on current outliers, potential outliers, and denials
•Identifies reviews that need to be completed on assigned floors and follows all assigned patients through completion and submission of Discharge Summary
•Assesses if all days are authorized/certified by respective payers and communicate any issues/denials to attending physician, CM, and department leadership
•Conducts UR until all tasks are completed; indicates UM Complete in authorization and/or certification
•Communicates with payer UR representatives on status/level of care authorizations that do not match MCG review
•Denotes relevant clinical information to proactively communicate with payers for authorizations of treatments, procedures, and Length of Stay; sends clinical information as required by payer
•Notifies appropriate parties of any changes in financial class including conversions, Hospital-Issued Notices of Noncoverage (HINN), Condition Code 44, and Important Message from Medicare (IMM).
•Follows department procedures and policies for Condition Code44, Physician Advisor review, and HINN processes
•Documents Avoidable Days/Delays, per department process/procedure/policy
•Priority 3: Maintains an Active Role in Denial Prevention and Management
•Uses payer MCG criteria and supporting documentation to justify the patient’s medical necessity for observation, admission and/or continued stay
•Proactively interacts with payers and proactively sends clinical reviews to prevent inpatient denials
•Proactively communicates with payer UM representatives on denials and coordinate peer to peer review with payer’s medical director
•Initiates and coordinates peer to peer reviews on all concurrent denials
•Understands payer requirements and government regulations to ensure compliant, safe, and cost-effective healthcare
•Priority 4: Identify Prolonged LOS patients, readmission, or complex discharge needs patients
•Identifies Prolonged LOS patients or complex patients/situations and communicate to the CM and/or Social Worker as appropriate
•Priority 5: Escalation
•Refers cases that require second level review to Physician Advisor, Manager, and Director per department process or procedure
•Discusses status/level of care and payment barriers with attending for resolution, if unsuccessful, escalate to department leadership and Physician Advisor, per department process or procedure
•Insurance and Utilization Management
•Maintains working knowledge of CMS requirements and readmission penalties
•Maintains working knowledge of insurance/payer benefits
•Documentation
•Documents accurately and in a timely manner in the Electronic Medical Record per program guidelines
•Utilizes standards of professional practice in all documentation and communication consistent with organization/department policy as well as the Board of Nursing and ethical guidelines established and universally supported by the nursing profession
•Assures documentation and patient information is secure and maintained in accordance with Billings Clinic policy, HIPPA, state and federal guidelines
•Professional Accountabilities
•Participates in continuing education, department planning, work teams and process improvement activities
•Maintains current Licensure
•Adheres to department and organizational policies addressing confidentiality, infection control, patient rights, medical ethics, advance directives, disaster protocols and safety
•Demonstrates the ability to be flexible, open minded and adaptable to change
•Maintains competency in organizational and departmental policies/processes relevant to job performance
•Utilizes standards of professional practice in all communication with patients, support systems and colleagues consistent with the Board of Nursing and ethical guidelines established and universally supported by the nursing profession
•Maintain utilization review data, as assigned by department.
•Performs all other duties as assigned or as needed to meet the needs of the department/organization