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Support the authorization department through utilization of clinical knowledge with associated treatments. Provides analysis of medical records to determine medical necessity in the clinical record and provides feedback to the providers and clinical team. Navigates high dollar treatments and provides additional clinical support as well as potential patient contact.

MINIMUM QUALIFICATIONS: EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. High school graduate or equivalent. 2. Current West Virginia licensure as a Licensed Practical Nurse (LPN). EXPERIENCE: 1. Two (2) years of healthcare experience.

PREFERRED QUALIFICATIONS: EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Associate or advanced degree preferred 2. Current West Virginia licensure as a Registered Professional Nurse.

CORE JOB DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Reviews the medical record for clinical documentation in relation to ordered treatment. Provides education to providers in relation to insurance policy of any variances.
2. Provides coordination of high dollar services that would include analyzing the medical record for medical necessity and provides authorizations. Acts as a point of contact for assigned services that will interact with the clinical leaders in the department.
3. Researches each request including reviewing medical policy to ensure each requests is processed with minimum delay and risk of denial.
4. Effectively communicates clinical information with payor to obtain authorization for appropriate level of care and procedure, and documents interactions in patient's electronic medical record (EMR).
5. Provides prompt follow up with the Payor to ensure current authorization and accurate payment for the patient's stay/treatment.
6. Provides prompt feedback regarding payor determination to Supervisor/Clinic, enabling them to evaluate/redirect the current patient plan of care in order to streamline the delivery of service.
7. Identifies pre-services denials by third party payor and notifies Supervisor/Clinic for immediate intervention.
8. Proactively communicates any change in payor information and follows up with payor to ensure services are authorized. Documents all changes and all payor information (i.e. DOS, Service (CPT/HCPC codes), LOC, Reference #, Authorization #, contact and phone number, and website used)... For full info follow application link.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities. Please view Equal Employment Opportunity Posters provided by OFCCP here. The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)