CLINICAL CLAIMS REVIEW NURSE MANAGER

JOB DESCRIPTION  POSITION TITLE: Clinical Claims Review Nurse Manager REPORTS TO:  Vice President of Health Services STATUS:  Full Time/Exempt   JOB SUMMARY:The Clinical Claims Review Nurse Manager is a liaison position between the claims department and the health services department.  This position is critical to the success of Arcadian Health Plan and as such is responsible for overseeing that authorized services are paid appropriately and claims submitted without prior authorization are reviewed for medical and coding appropriateness before payment is rendered. The Clinical Claims Review Nurse Manager is responsible for setting departmental processes between the claims department and health services department for clinical review of claims without authorization to determine medical necessity, coding accuracy, and billing appropriateness.  Additionally, the Clinical Claims Review Nurse Manager coordinates and manages the relationship with Arcadian’s claims audit vendor to ensure that claims are reviewed not only for coding/billing appropriateness but for medical necessity per Medical Guidelines (e.g.: InterQual) and CMS guidelines.   Additional responsibilities include working closely with Arcadian’s Benefit Administrator providing input to Arcadian’s Benefit Interpretation Manual, triaging to the appropriate Community Focus Nurse claims requiring clinical review, processing expedited clinical review of claims that are close to falling out of compliance, providing feedback regarding authorization documentation and process improvements  recommendations surrounding DRG’s HHRG’s, RUGs reviews and payments.  This position is multifaceted; requiring a diverse set of management and organizational skills, as well as clinical expertise.     QUALIFICATIONS: Education:  § Current, valid facility coding certificate required; professional services a plus§ Current, valid nursing license (RN/LVN) in the state of California. Ability to obtain valid nursing license in other states that Arcadian Health Plan may enter the Medicare Advantage market. § Bachelor of Science degree preferred.    Experience:  § Minimum of 3-5 years of facility coding/billing experience § Experience with Medicare billing practices, DRG’s HHRG’s, RUGs, CPT/ICD-9CM § Experience applying Inter Qual,, Milliman, or other practice management guidelines.§ Experience conducting utilization management/case management reviews§ Minimum of 3-5 year hospital acute care nursing or equivalent; would consider skilled nursing facility or recent home health experience§ Familiarity with Code of Federal Regulations (CFR)§ Familiarity with the CMS website, CMS Manuals§ Experience with computer and software programs (e.g.; Microsoft Word, Excel) and the internet  § Skills:§ Code Medical Records following CCI§ Ability to research complex issues as it relates to Medicare benefits and coding/billing practices, synthesize the information, concisely communicate either verbally or in writing findings and recommendations. § Ability to apply InterQual, Milliman, or other practice management guidelines to determine medical necessity/appropriateness of coding and billing§ Independent thinker, logical, strategic, with an attention to detail§ Effective communication style (written and verbal) with proven ability to positively influence behavior and arrive at a “win-win” resolution§ Strong computer skills, including the internet, ability to quickly research complex issues§ Competent administrative and organizational skills, ability to multitask and set priorities§ Professional demeanor§ Ability to:§ creatively solve problems § develop and write policy and procedures§ implement policies and procedures§ perform data analysis and prepare reports§ occasional travel to Arcadian Health Plan regional offices (e.g.; driving to local hospitals, flying) § Job Duties and Responsibilities: § Set up departmental processes and work flows between the claims department and health services department for clinical review of claims without authorization to determine medical necessity§ Coordinate and manage relationship with claims audit vendor to ensure that claims are reviewed not only for coding/billing appropriateness but for medical necessity via CMS guidelines. § Establish close working relationship with Arcadian’s Benefit Administrator and provide input/feedback regarding Arcadian’s Benefit Interpretation Manual§ Establish process to triage claims requiring clinical review to the appropriate Community Focus Nurse and follow up to ensure review is processed within claims compliance time frames§ Develop and implement a training program for Community-Focus Nurses on best practices for retrospective clinical claims review.§ Process expedited clinical review of claims that are close to falling out of compliance§ Provide feedback to UM Directors and IC Supervisor regarding authorization documentation, policy and procedures§ Identify cases that might benefit from complex case management/hospice and refer to case management/TPL for consideration.  Referrals to case management to include rationale for consideration.§ Provide recommendations to VP Health Services on DRG’s HHRG’s, RUGs, CPT/ICD-9CM coding as it relates to the authorization processes§ Make recommendations for changes to the authorization process and list  Physical Requirements of the Position:§ Sitting:  The essential functions of this job are performed while seated at a desk or work station for at least 50% of scheduled work hours§ Standing and walking: The essential functions of this job require the ability to move from one location to another either by walking, driving, or flying.§ Hearing:  Must be able to receive and send detailed information through oral communication and clearly understand people speaking in her/his presence and over the telephone§ Speaking:  The essential functions of this position require speaking and communicating English in a clearly understood voice at all times during scheduled work hours§ Fingering and repetitive motions:  Functions of this position require a fair amount of movements of the wrists, hand, fingers in the use of office equipment such as phones and computer keyboards§ Vision:  The essential functions of this position require the ability to clearly see detailed information via written manuscript and or computer§ Lifting:  A function of this position requires the ability to lift at least twenty-five pounds on an occasional basis§ Availability by phone, fax, or cell phone when out of the office Salary:  Starting salary is based on qualifications and experience.  In addition, in accordance with California state requirements, Arcadian does not permit or provide compensation or anything of value to its employees or agents, condition employment of its employee or agent evaluations, and set its employee or agent performance standards, based on the volume of adverse determinations, reductions or limitations on lengths of stay, benefits, services, charges or on the number of frequency of telephone calls, or other contacts with health care providers or patients.   Approved:   VP of Health Services Date   Medical Director Date