Job Description

Job Title: Revenue Cycle Clinical Review Nurse
Job ID: 694688
Status: Full-Time
Regular/Temporary: Regular
Hours:
Shift: Day Job
Facility:
Department: Rev Cyc Care Mgmt
Location: 2 Hot Metal Street, Pittsburgh PA 15203

Description

The Revenue Cycle Clinical Review Nurse provides support to the local care management departments by initiating the retrospective appeal process for acute inpatient clinical denials and audits. In addition, the nurse will serve as a clinical resource person for all Health Services Division areas. Drawing on a clinical knowledge base and knowledge of payor regulations, the Revenue Cycle Clinical Review Nurse is responsible for assessing the presence of criteria to recover denied reimbursement or support services rendered.

Responsibilities:
  • Apply understanding of utilization management as it relates to the continuum of care.
  • Assist in clearing claims for billing as indicated.
  • Assist in determining system-wide care management needs through investigation of retrospective denials or revenue cycle audits, and identification of root cause.
  • Assist the Health Services Division in responding to billing inquiries/complaints, which require a clinical understanding.
  • Collaborate with other departments to ensure all information to support services rendered is identified.
  • Collaborate with physician leadership as warranted in preparation of appeal/clinical review responses.
  • Complete timely and accurate appeals and/or clinical reviews using established processes.
  • Coordinate payor audits, conduct post-audit to validate auditor findings and identify previously unbilled services.
  • Formulate written appeal letter or clinical summary as appropriate, incorporating supportive documentation. (i.e. medical criteria, state regulations, etc).
  • Identify and assign a root cause to each case to ensure denial reasons are tracked.
  • Maintain collaborative relationships with utilization management and appeal departments at payor organizations.
  • Maintain current knowledge of regulatory guidelines related to retrospective appeals and clinical reviews.
  • Monitor and evaluate for areas of process improvement related to the retrospective appeal/3rd party audit process to ensure regulatory compliance.
  • Negotiate agreement with payor regarding final outcome.
  • Perform clinical review for cases including but not limited to those referred for retrospective appeal, 3rd party audit, or validation of services rendered.
  • Serve as a clinical liaison between revenue cycle staff, utilization review, payors and physicians when indicated.

Qualifications

  • BSN or Bachelors degree preferred
  • Five years clinical experience required
  • Two years payor or care management experience preferred
  • Three to five years in a health care financial environment preferred
  • Knowledge of medical necessity criteria (InterQual) preferred
  • Knowledge of CPT-4 and Revenue Coding is strongly preferred
  • Prior appeal/grievance experience preferred
  • Knowledge of payer reimbursement structure preferred
  • Excellent oral and written communication skills
  • Negotiation skills
  • Critical thinking skills 
  • Organization/time management and prioritization skills
  • Proficient in Microsoft Word and Microsoft Excel

Licensure, Certifications, and Clearances:
  • RN Licensure in state of Pennsylvania is required
  • Act 34 Criminal Clearance

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $28.37 to $47.88

Union Position: No

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