Trinity Health Clinical Pre Service Nurse Coordinator in Newtown, Pennsylvania
Trinity Health Mid-Atlantic is looking for Clinical Pre Service Nurse Coordinator to join our Pre Service team!
The Clinical Pre-Service Nurse Coordinator is directly responsible for reviewing pre/post service initial denials, securing escalated insurance authorizations, handling escalated medical necessity reviews and coordinating with Patient Access, Mid-Revenue Cycle and Patient Business Service (PBS) to identify opportunities for revenue optimization
Schedule: Full-time (40 hours)
While this role is remote, there will be occasional need to be on site for training and meetings.
Clinical Pre Service Nurse Coordinator
Works closely with Physician Providers to assure that the proposed intensity of service is in alignment with the severity of illness and accurately documented to support level of care determinations and required authorizations.
Investigates denials and root causes and tracks and reports trends to remediate issues and assist with internal process improvement.
Leverages clinical knowledge and standard procedures to ensure timely attention to denials as requested by PBS and assists in the research and application of regulatory policies to support administrative appeals.
Communicates pertinent clinical information to Physicians, Medical Directors, and CFO, as indicated, regarding evaluation of medical appropriateness and/or payer determinations.
Understands clinically complex medical situations and communicates appropriately with insurers as needed.
Maintains a working knowledge of applicable Federal, State, and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior.
Utilizes working knowledge of basic coding guidelines for medical necessity and insurance authorization escalations and/or denials.
Awareness of how to navigate payer websites to occasionally validate insurance eligibility and authorizations.
Familiarity with the construction of professional appeals in response to denied claims.
Pennsylvania State Registered Nurse or Licensed Vocational Nurse/ Licensed Practical Nurse and graduate of an accredited school of nursing, plus at least two (2) years of nursing experience
Minimum two (2) years of pre-certification/prior approval clinical denial unit management experience
Demonstrated knowledge of patient access, revenue cycle and denial management functions. Certification and/or membership in AAPC, AHIMA, HFMA, AAHAM, NAHAM strongly preferred.
Demonstrates an understanding of technical and clinical denials areas, such as: medical necessity, eligibility issues, no authorization. Working knowledge of medical terminology, and medical record coding experience (ICD-9, CPT, HCPCS) are highly desirable.
Working knowledge of Epic Prelude and Resolute, including associated work queues is preferred.
Strong organizational, task prioritization, resource management skills
Excellent written and oral communication & presentation skills.
May be require travel up to 10% between locations within the Trinity Mid-Atlantic Region
We offer a competitive salary and comprehensive benefits including:
Medical, Dental, & Vision Coverage
Retirement Savings Program
Paid Time Off
Our Commitment to Diversity and Inclusion
Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
EOE including disability/veteran
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