• Performs retrospective (post �discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
• Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual� criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.
• Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process.
• Demonstrates proficiency in use of medical necessity criteria sets, currently InterQual�, as evidenced by Inter-rater reliability studies and other QA audits.
• Demonstrates proficiency in utilization of electronic tools including but not limited to ACE, MedAssets (formerly IMaCs), eCARE, Authorization log, InterQual�, VI, HPF, as well as competency in Microsoft Office.
• Demonstrates basic patient accounting knowledge i.e. UB92/UB04 and EOB components, adjustments, credits, debits, balance due, patient liability, etc.
• Additional responsibilities:
• Serves as a resource to non-clinical personnel.
• Provides CRC leadership with sound solutions related to process improvement
• Assist in development of policy and procedures as business needs dictate.
• Assists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.

KNOWLEDGE, SKILLS, ABILITIES

• Demonstrates proficiency in the application of medical necessity criteria, currently InterQual�
• Possesses excellent written, verbal and professional letter writing skills
• Critical thinker, able to make decisions regarding medical necessity independently
• Ability to interact intelligently and professionally with other clinical and non-clinical partners
• Demonstrates knowledge of managed care contracts including reimbursement matrixes and terms
• Ability to multi-task
• Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.
• Ability to conduct research regarding off-label use of medications

EDUCATION / EXPERIENCE

• Must possess a valid nursing license (Registered or Practical/Vocational)
• Minimum of 5 years recent acute care experience with the last 2 years in a facility environment
• Medical-surgical/critical care experience preferred
• Minimum of 2 years UR/Case Management experience within the last 2 years
• Managed care payor experience a plus either in Utilization Review, Case Management or Appeals
• Patient Accounting experience a plus
• Previous classroom led instruction on InterQual� products (Acute Adult, Peds, Outpatient and Behavioral Health) preferred

• Current, valid RN/LPN/LVN licensure
• Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM) preferred

PHYSICAL DEMANDS

• Ability to lift 15-20lbs
• Ability to travel approximately 10% of the time; either to facility sites, National Insurance Center (NIC) sites, Headquarters or other designated sites
• Ability to sit and work at a computer for a prolonged period of time conducting medical necessity reviews

• Characteristic of typical office environment requiring use of desk, chair, and office equipment such as computer, telephone, printer, etc.

• May require travel � approximately 10%
• Interaction with facility Case Management, Physician Advisor is a requirement.

Employment practices will not be influenced or affected by an applicant�s or employee�s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.