Referral Clinical Review RN FT

Summary:
Establishes medical necessity for advanced services and procedures. Liaisons with providers, payers, and others to facilitate navigation of complex authorization and reimbursement processes.

Work Schedule: Full Time Days

Responsibilities:
Reviews clinical documentation and guidelines for pending referrals, calling when necessary in an attempt to obtain authorization, mitigating the need for physician calls. Facilitates peer-to-peer reviews as needed.

Identifies documentation requiring clarification, communicating with providers or other healthcare professionals to ensure medical necessity is supported. Serves as a resource to providers and other healthcare professionals regarding appropriateness of clinical documentation.

Determines that medical necessity documentation and intent is established to meet Medicare compliance for diagnosis codes entered by providers. Changes diagnosis codes and documents details in EMR as needed.

Initiates complex referrals on authorization portals, and trouble-shoots how best to navigate portals to obtain authorizations upon submission.

Withinscope of job, requires critical thinking skills, decisive judgement and theability to work with minimal supervision. Must be able to work in afast-paced environment and take appropriate action.