Utilization Review
Company: Able Home Care
Location: Peabody
Posted on: May 6, 2022
Job Description:
Job DescriptionThis is NOT a Remote Position - Individual MUST
fully vaccinated.This Nurse has overall responsibility for the
Prior Authorization Process.The Nurse will receive referrals for
Home Health Services and start the referral process by creating a
Pending Admission - all referral information will be entered into
Clinical Software via the Patient Profile. Pending Admissions are
patients categorized as "pre-admit" entered into the system either
as a New Patient or as an Existing Referral. In addition Nurse
will:
- Update and maintain referrer, physician and payor
libraries
- Create new patient record and/or validate information in
current admission/episode.
- Review paperwork received through intake and upload to
pre-admit chart.The Nurse is also responsible for obtaining
insurance verifications and authorizations for any patient that
will be billed through a third-party insurance company including
MassHealth (Medicaid) and Medicare Advantage Plans via provider
online service center and web-portals. Tasks to include but not
limited to:
- Coordination of member Benefits and identify Third-Party
Payors.
- Contact company to determine insurance eligibility and need for
prior-authorization.
- Complete Insurance Verification.
- Consult with area management to determine if referral can be
accepted based on requirements of payor.
- Assist in determining appropriate insurance billed, projected
frequency, reason for home care services, and confirm paperwork
received has all required documentation, dates, and
signatures.Diagnosis, medications, and appropriateness of care will
be discussed with QI, Area Clinical Manager, Billing Manager and
Scheduler to generate and assign the evaluation visit.Prior
Authorization and Medical Necessity Determination to include but
not limited to:
- Work with members, providers, and multidisciplinary team
members to assess, facilitate, plan, and coordinate service
requests from members or providers against evidence based clinical
guidelines.
- Perform pre-service authorization reviews and timely
communication of clinical information supporting pre-authorization
reviews.
- Ensure compliance with authorization requirements as defined by
insurer or payor as well as initiate authorization requests with
aforementioned entities.
- Consults with physicians to ensure clinically appropriate
determinations.Other duties as assigned.
Keywords: Able Home Care, Peabody , Utilization Review, Other , Peabody, Massachusetts
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