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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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