United Surgical Partners International Inc (USPI)
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Revenue Integrity Coordinator
at United Surgical Partners International Inc (USPI)
Role and Responsibilities
The primary responsibility for the Revenue Integrity Coordinator will be to work closely with the Care Coordination teams, which include Scheduling, Pre-Certification and Case Managers at the Hospitals to ensure the proper procedures are being followed to ensure that the correct procedures/supplies are being authorized.
- Review Post-Operative Reports to ensure the scheduled procedure coincides with what was performed within the timeframe allowed by the Insurance Companies.
- Request a new/additional authorization from the Insurance Company if the scheduled procedure differs from what was performed.
- Review medical records and prepare clinical appeals (when appropriate) on medical necessity, level of care, length of stay, and authorization denials for patients.
- An understanding of the severity of an array of illnesses, intensity of service, and care coordination needs are key, as the nurse must integrate clinical knowledge with billing knowledge to review, evaluate, and appeal clinical denials related to the care provided to the patient.
- The Revenue Integrity Coordinator will work with the multidisciplinary team to assess and improve the denial management, documentation, and the appeals process of such findings.
- The Revenue Integrity Coordinator will manage all activities related to the monitoring, interpreting, and appealing of clinical denials received from third-party payers and ensures accuracy in patient billing.
- The position is integral to the organization, as successful appeals by the Revenue Integrity Coordinator will result in the overturning of denied claims and recovered revenue for the Hospitals.
- The position will educate the Schedulers, Pre-Certification Staff and the Case Managers with processes to identify an opportunity to ensure that all procedures are authorized and other special equipment and/or implants will be covered by the Insurance Company.
- Advanced understanding of Medicare, Medicaid and Commercial Insurance standards and requirements.
- Competent application of InterQual and/or Milliman criteria.
- Excellent written and oral communication skills are a must, as is the ability to work and meet deadlines in a fast-paced environment.
- Computer technology proficiency, such as Word, Excel, and Outlook
QUALIFICATIONS AND EDUCATION REQUIREMENTS
- High School graduate or equivalent required
- Current license as a Licensed Vocational Nurse or Registered Nurse in Texas
- 1 to 3 years of experience in Utilization Review/Case Management, to include working Denials and/or Appeals is preferred.
- Relevant clinical experience in a Hospital setting preferred.