Position Summary

Responsible for follow-up on rejected and denied claims using evidence based support and other documentation as needed. Works with Medical Information Management to ensure proper ICD9 and CPT4 coding are performed on each claim. Responsible for identifying trends in denials and providing education to clinical staff and managed care payers to reduce these denials; Gather all clinical and supporting evidence and submit to payers for pre-determination of off-label services and/or complex procedures and treatment modalities; Communicate status of pre-determination request to stakeholders; Educate clinical and other staff on off-label definitions and policies and requirements for authorization on other complex cancer treatment modalities; Provide clinical support to non-clinical pre-certification staff as needed. Must have a strong understanding of the disease implications, use of various treatment modalities, and expected outcomes.

Organizational Expectations

• Practices within the Medical Centers policies and procedures.
• Adheres to the Intensive Caring Value statements as demonstrated through positive patient/guest relations, positive and effective interactions with staff and formulating and meeting developmental goals.

Minimum Qualifications

For Hire Required:

• Associates degree required or equivalent experience.
• Minimum of 3 years experience in the field of oncology or equivalent medical experience
• Excellent verbal and written skills required.
• Experience with Windows, Excel, Access, and intranet/internet navigation tools required.

For Hire Preferred:

• Bachelors degree in nursing with solid clinical skills and current clinical practices preferred.
• Ability to influence clinical processes through appropriate data collection, investigation of research, and negotiation of required documentation by key stakeholders.
• Knowledge of all aspects of the revenue cycle: Scheduling; patient flow through the system for both, inpatient and outpatient; patient placement, charge entry; diagnosis coding; billing.
• Operational knowledge of the primary revenue cycle systems (EPIC) along with systems processes preferred.
• Experience in physician practice and/or utilization review a plus.
• Knowledge of Medicare and commercial insurance reimbursement a plus.
• Strong knowledge of ICD-10-CM, HCPCs, and CPT coding preferred.

Job Relationships

Supervisory Responsibility: None

Contacts: Utilization Management, Patient Access, Patient Accounting and Finance staffs, IS, operational departmental managers and cost center contacts, physicians and administrative staff of other hospital entities as well as OSUMC administration.

Responsible to: Manager, Revenue Cycle Clinical Support

Physical/Visual/Mental Requirements

While performing the duties of this job, the employee must be able to:

• Occasionally lifts objects of 20 pounds or less from one level to another as in moving office supplies, computer paper, etc.
• Occasionally carries objects in; hands, arms or on shoulders of 20 pounds or more as in carrying stacks of reports or boxes of computer paper.
• Occasionally pushes objects of greater than 80 pounds, so that it moves away from or stays in front of you, e.g. pushing objects on a cart.
• Occasionally stands on feet without moving about.
• Frequently walks about on foot.
• Frequently sits in a normal and seated position as in operating a PC.
• Frequently stoops or crouches by bending legs and spine or by bending downward or forward at waist as in moving supplies.
• Frequently reaches by extending hand(s) and arm(s) in any direction.
• Constant finger dexterity required to manipulate objects with fingers rather than with the whole hand(s) or arm(s) as in retrieving information and data entry via PC.
• Constant talk to produce clear, intelligible speech in responding to inquiries and giving direction and information.
• Constant hearing to understand voice communication or audible signals as in listening and responding to inquiries.
• Occasional far visions to see objects beyond 20 feet.
• Constant near vision to see objects within 20 inches as in retrieving information.
• Constant field of vision to see an area up and down or right and left while eyes are fixed on one point as in retrieving information via PC.
• Constant sharp focus to adjust vision when doing close work that changes in distance from your eyes as in utilizing PC and awareness of surrounding environment.
• Constant visual concentration and/or attention to focus thoughts or efforts for periods of time (i.e. looking at a computer screen for extended periods of time, retrieving information, data entry.)

Work Environment

The work environment involves everyday risks or discomforts which requires normal safety precautions typical of such places as offices and meeting rooms (i.e. use of safe work practices, avoidance of trips and falls, and observance of fire regulations and traffic signs).

There is a possibility of working from home in this position. Must have high speed internet. Requirements are to have satisfactory performance appraisals, not be in corrective action, be self-motivated and organized. Work from home is at managements discretion. Staff are expected to report in house for once a month meetings and others as assigned.

Note: The above statements are intended to describe the essential functions and related requirements of persons assigned to this job. They are not intended as an exhaustive list of all job duties, responsibilities, and requirements.