Description:
GENERAL SUMMARY
Responsible for reviewing and analyzing information to make medical determinations as necessary. Applies clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care in cases requiring prospective, concurrent, or retrospective utilization review.
ESSENTIAL RESPONSIBILITIES
Based on area of specialization, employee may perform any or all of the responsibilities listed below.
Claims Review
- Conducts medical reviews of individual provider and hospital claims for coding and billing accuracy and medical appropriateness for all products in support of company medical payment policies and cost containment initiatives.
- Processes and/or reviews claims for compliance and level of care in a timely manner that meets or exceeds production and quality goals. Reviews all complex physician, facility, and specialty claims and adjustments to ensure compliance with company policies and procedures.
- Assesses, investigates and resolves information to respond to difficult inquiries including, but not limited to, authorizations, payments, denials and coordination of benefits.
- Interfaces with customers by telephone, correspondence and/or in person to answer questions and resolve process issues.
Utilization Management
- Conducts retrospective medical necessity and experimental/investigational reviews of inpatient admissions, diagnostic testing and ambulatory services. Meets health plan or applicable accreditation organizational requirements for decision-making and notification process timeframes.
- Utilizes established criteria to authorize inpatient admissions, diagnostic testing and ambulatory services. Makes referrals to the health plan/clinical operations Medical Director for determinations when criteria are not met.
- Communicates determinations verbally and/or in writing to appropriate business department as required by the health plan/business department internal workflow policies.
Pre-Existing Condition Review
- Coordinates, directs, and performs retrospective reviews of individual medical history to identify possible pre-exiting conditions.
- Conducts analysis and research of medical and claims history to make payment determination.
- Actively identifies possible fraud/misrepresentation cases. May assist with preparation of cases for referral to medical underwriting and medical management.
All Functions
- Identifies training needs within the team. May train service teams based on outcomes of medical reviews as well as process and/or procedure changes.
- Drives the team to identify and implement process improvements; encourages ownership of and group participation in improvement initiatives.
- Identifies and recommends opportunities for cost savings and improving outcomes.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered Nurse with a current RN license in good standing in the state where job duties are performed.
- Bachelor’s degree and/or Certified Professional Code-CPC-H preferred.
- Previous (3-5 years) clinical experience.
- Knowledge of medical terminology and ICD-9, CPT-4, and HCPCS coding.
- Working knowledge of coordination of benefits and health care products under both fully insured and self-funded arrangements preferred.
- Strong analytical and problem solving skills.
- Excellent organizational, interpersonal and communication skills.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Louisville, KY, US
Other Locations: ,
Organization: 38500 - Coventry Health & Life-KY
Schedule: Full-time
Job Posting: 2013-04-15 00:00:00.0
Job ID: 1311382
GENERAL SUMMARY
Responsible for reviewing and analyzing information to make medical determinations as necessary. Applies clinical knowledge to assess the medical necessity, level of services, and/or appropriateness of care in cases requiring prospective, concurrent, or retrospective utilization review.
ESSENTIAL RESPONSIBILITIES
Based on area of specialization, employee may perform any or all of the responsibilities listed below.
Claims Review
- Conducts medical reviews of individual provider and hospital claims for coding and billing accuracy and medical appropriateness for all products in support of company medical payment policies and cost containment initiatives.
- Processes and/or reviews claims for compliance and level of care in a timely manner that meets or exceeds production and quality goals. Reviews all complex physician, facility, and specialty claims and adjustments to ensure compliance with company policies and procedures.
- Assesses, investigates and resolves information to respond to difficult inquiries including, but not limited to, authorizations, payments, denials and coordination of benefits.
- Interfaces with customers by telephone, correspondence and/or in person to answer questions and resolve process issues.
Utilization Management
- Conducts retrospective medical necessity and experimental/investigational reviews of inpatient admissions, diagnostic testing and ambulatory services. Meets health plan or applicable accreditation organizational requirements for decision-making and notification process timeframes.
- Utilizes established criteria to authorize inpatient admissions, diagnostic testing and ambulatory services. Makes referrals to the health plan/clinical operations Medical Director for determinations when criteria are not met.
- Communicates determinations verbally and/or in writing to appropriate business department as required by the health plan/business department internal workflow policies.
Pre-Existing Condition Review
- Coordinates, directs, and performs retrospective reviews of individual medical history to identify possible pre-exiting conditions.
- Conducts analysis and research of medical and claims history to make payment determination.
- Actively identifies possible fraud/misrepresentation cases. May assist with preparation of cases for referral to medical underwriting and medical management.
All Functions
- Identifies training needs within the team. May train service teams based on outcomes of medical reviews as well as process and/or procedure changes.
- Drives the team to identify and implement process improvements; encourages ownership of and group participation in improvement initiatives.
- Identifies and recommends opportunities for cost savings and improving outcomes.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Registered Nurse with a current RN license in good standing in the state where job duties are performed.
- Bachelor’s degree and/or Certified Professional Code-CPC-H preferred.
- Previous (3-5 years) clinical experience.
- Knowledge of medical terminology and ICD-9, CPT-4, and HCPCS coding.
- Working knowledge of coordination of benefits and health care products under both fully insured and self-funded arrangements preferred.
- Strong analytical and problem solving skills.
- Excellent organizational, interpersonal and communication skills.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Louisville, KY, US
Other Locations: ,
Organization: 38500 - Coventry Health & Life-KY
Schedule: Full-time
Job Posting: 2013-04-15 00:00:00.0
Job ID: 1311382