Clinical Case Specialist
Team member is responsible for the accurate and complete review of medical records required in support of medical necessity criteria for patients utilizing Negative Pressure Therapy, according to the Acelity Code of Conduct. Clinical Case Specialist will manage all level claims appeals and coordinate Peer-to-Peer requests where presentation of existing medical records to 3rd party Payor is required. Documentation relating to appeals and claims should abide by payor’s guidelines and regulations. Team Member should become familiar with each case individually, according to relevant payor guidelines and coverage criteria to determine the viability of release and/or successful appeal. Clinical Case Specialists are required to manage, maintain, and communicate order activity to appropriate stakeholders, and report potential, or emerging coverage trends related to payor denials and payor clinical criteria interpretations. Specialists will work with management to develop education and other performance improvement initiatives to improve clinical review quality and efficiency while mitigating lost revenue related to medical necessity denials.
- Analyze patient orders to assess wound qualification(s) based on payor specific coverage criteria
- Educate customer service representatives, field sales representatives and clinical counterparts, management, and customers to include case managers, doctors, discharge planners, and nurses on best practices for documentation required to support claims processing
- Provide product support on V.A.C. NPWT equipment and address questions within their scope of practice and education regarding KCI clinical guidelines for NPWT use.
- Review orders identified as potential for discontinuation of therapy, and orders at risk for lost revenue, e.g. incomplete records not being received by KCI, with focus on proactively working with clinical providers to collect required documentation, and address coordination of care, to meet Payor Coverage Criteria
- Monitor and adjust patient statuses based on changing needs and conditions
- Coordinate referrals, peer to peers, and all level appeals to include claims appeals
- Address any patient concerns with appropriate parties
- Manage set goals and metrics including but not limited to, quality appeal submissions, high-cycle patient placements and mitigating revenue loss due to lack of documentation.
- Preserve patient product and customer service needs while maintaining organizational goal of continuous process improvement to meet performance indicators such as: unbilled, lost days, discontinuation of therapy, and cancellations as appropriate.
a) BASIC QUALIFICATIONS
- Current licensed Registered Nurse (RN) or Vocational (Practical) Nurse (LVN)
- Minimum 2 year of clinical experience
b) SKILLSET REQUIRMENTS
- Excellent verbal and written communication skills, strong listening skills, critical thinking and analytical skills, problem solving skills,
- Intensive writing capabilities/efficiencies
- Ability to communicate with multiple levels within the organization (e.g. managers, physicians, clinical and support staff)
- Ability to maintain a strong relationship with other teams and work collaboratively to positively affect clinical and financial outcomes
- Excellent organizational skills including effective time management, ability to set priorities, participate in process improvement to eliminate roadblocks and creates focus.
- Ability to apply InterQual and Milliman Care Guidelines (MCG) medical necessity criteria to a case as applicable
- Ethics and Values - Adheres to an appropriate and effective set of core values acts in line with those core organizational values and team goals;
- Customer Focus - Is dedicated to meeting the expectations and requirements of internal and external customers; gets first hand customer information and uses it for improvements in products and services; acts with the customers in mind; establishes and maintains effective relationships with customers to gain and maintain their trust and respect.
- Decision Quality - Makes good decisions based upon a mixture of analysis, experience, and sound judgment; most of his/her solutions and suggestions are accurate over time; sought out by others for advice and solutions.
- Drive for Results – Self-motivated, able to exceed goals successfully; is consistently a top performer; bottom-line orientated; steadfastly pushes self and others for results.
- Peer Relationships - is seen as a team player easily gains trust and support of peers; encourages collaboration; can be candid with peers.
- Creativity - Is innovative and provides fresh input and feedback by participating in brainstorming settings.
- Experience working in case management
- Knowledge of regulatory requirements by payor type
- Experience working with payor specific medical criteria
The information listed above is not a comprehensive list of all duties/responsibilities performed.
This job description is not an employment agreement or contract. Management has the exclusive right to alter this job description at any time without notice.The information listed above is not a comprehensive list of all duties/responsibilities performed. This job description is not an employment agreement or contract. Management has the exclusive right to alter this job description at any time without notice. Any physical and mental requirements described in this job description are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. EOE AA M/F/Vet/Disability: Acelity L.P. Inc. and its subsidiaries are an equal opportunity and affirmative action employer and give consideration for employment to qualified applicants without regard to race, ethnicity, color, religion, sex, sexual orientation, gender identity, pregnancy, national origin, age, disability, veteran status, or genetic information or any other legally protected characteristic. If you'd like more information about your EEO rights as an applicant under the law, please click here: http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf VEVRAA Federal Contractor