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Revenue Cycle Clinical Review Nurse

  • Job ID: 166140108
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: Corporate Revenue Cycle
  • Department: Rev Cyc Care Mgmt
  • Location: 2 Hot Metal Street, Pittsburgh PA 15203
  • Union Position: No
  • Salary Range: $30.17 to $50.94 / hour

Description

UPMC Corporate Revenue Cycle is hiring a Revenue Cycle Clinical Nurse to join our team!  This role will work remotely, however will need access to come into Quantum I to gain documents as needed.

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.

Do you have five years in clinical experience and are ready to use your prior appeal experience in your next career?  If so, this could be the role for you!

Responsibilities:

  • Apply understanding of utilization management as it relates to the continuum of care.
  • Assist in determining system-wide care management needs through investigation of retrospective denials or revenue cycle audits, and identification of root cause.
  • Coordinate payor audits, conduct post-audit to validate auditor findings and identify previously unbilled services.
  • Serve as a clinical liaison between revenue cycle staff, utilization review, payors and physicians when indicated.
  • Monitor and evaluate for areas of process improvement related to the retrospective appeal/3rd party audit process to ensure regulatory compliance.
  • 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.
  • Identify and assign a root cause to each case to ensure denial reasons are tracked.
  • Formulate written appeal letter or clinical summary as appropriate, incorporating supportive documentation. (i.e. medical criteria, state regulations, etc).
  • Assist in clearing claims for billing as indicated.
  • Maintain current knowledge of regulatory guidelines related to retrospective appeals and clinical reviews.
  • Maintain collaborative relationships with utilization management and appeal departments at payor organizations.
  • 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.
  • Complete timely and accurate appeals and/or clinical reviews using established processes.
  • Collaborate with physician leadership as warranted in preparation of appeal/clinical review responses.

 

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.
  • Registered Nurse (RN)

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life — because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct