Clinical Authorization Specialist | PAM Health Corporate
Clinical Authorization Specialist | PAM Health Corporate
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Job Description
Overview
The Clinical Authorization Specialist is responsible for managing Commercial and Medicare Advantage admission authorizations by conducting a comprehensive analytic review of clinical documentation to determine if a patient is clinically appropriate for admission and the best course of action to obtain authorization from the payer. The Clinical Authorization Specialist will write sound compelling factual argument for the purpose of admission and/or to overturn a denial received from a payor for admission.
If youre looking for a schedule that fits your lifestyle check out PAM Health- andask us about our comprehensive benefits package!
Some things that our hospital can offer YOU as a full-time employee:
- Medical Benefits: EPO/HDHP/HSAoptions including prescription coverage Rx nGo and Teladoc
- Comprehensivedental and vision benefits
- Employee Assistance Program includingcounseling legal and financial service
- Flexible spending (FSA) and health savings(HSA)accounts
- Life and Disability insurancebenefits
- Education/In-Service Opportunitiesincluding continuing education and tuitionassistance
- Supplemental benefits: Accident critical illness cancer pet and identity theftprotectioninsurance options
- Auto Home Cell Phoneand Gym Membership discountofferings
- Personal Travel Discounts
- Employee Bonus Referral Program
- 401(k) plansand discretionary employer match
- Generous Paid Benefit Time
Responsibilities
- Reviews patient medical records and utilizes clinical and regulatory knowledge and skills as well as has knowledge of payor requirements to determine the appropriateness of the admission.
- Utilize pre-existing criteria other resources and clinical evidence to develop sound and well-supported admission arguments.
- Prepares convincing arguments using pre-existing criteria sets and/or clinical evidence from existing clinical references and/or regulatory arguments and prepares requests to the payor in an effort to obtain admission authorization or overturn an initial denial in a professional and concise manner.
- Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
- Prepares feedback for summaries of appeal activities by hospital to be included in the Monthly Operations Reports.
- Has the ability to proficiently read understand and communicate in writing abstract information from patient medical records in a professional manner. Demonstrates excellent written communication. Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; and presents numerical data effectively.
- Ensures compliance with HIPAA regulations including confidentiality as required
Maintains the highest level of customer service via courtesy compassion and positive communication.
Promotes the Mission and Vision of Post Acute Medical within the work environment and the community.
Respects dignity and confidentiality by adherence to all applicable policies and procedures.
Qualifications
- Education and Training: Bachelors or Associates degree in nursing preferred.
- Knowledge in the area of LTAC and IRF Criteria including: Medicare InterQual and Milliman are preferred.
- Currently licensed as an RN preferred.
- Experience: Five years (5) experience as a clinical nurse in an acute care addition having at least two years of experience in appeals case management discharge planning and/or utilization review is preferred.
Required Experience:
Unclear Seniority
Employment Type
Full-Time
