<ul> <li> <p>Position Summary</p> </li><li> <p>Under general supervision, clinically reviews and provides necessary patient information to third party payors to obtain insurance authorizations for Mary Greeley to perform ordered services which supports financial stability of the organization.</p> </li><li> <p>Position Responsibilities</p> </li><li> <p>Unit Specific Position Responsibilities</p> </li><li> <p>Monitors and manages workqueues associated with orders, referrals and scheduled services.</p> </li><li> <p>Interprets physician referrals and orders for procedures and diagnostic tests.</p> </li><li> <p>Utilizes clinical knowledge to obtain prior authorization for referrals and orders.</p> </li><li> <p>Evaluates patient eligibility based on coverage and specific payer medical policy requirements for ordered services.</p> </li><li> <p>Reviews current and past medical history as well as other treatment attempts.</p> </li><li> <p>Documents and maintains information in the patient medical record.</p> </li><li> <p>Maintains a clinical appeal process for denied authorizations.</p> </li><li> <p>Establishes and maintains a means for communicating and collaborating with physicians, other team members and departments, as well as patients.</p> </li><li> <p>Serves as liaison between insurance companies and Mary Greeley Medical Center. Will use clinical knowledge to help resolve issues raised by insurance companies relating to prior authorization of treatment and care.</p> </li><li> <p>Acts as a clinical resource to non-clinical healthcare personnel.</p> </li><li> <p>Utilizes knowledge of available equipment, policies, procedures, and strategies to effectively ensure the protection and safety of patients, data, and property.</p> </li><li> <p>Participates in staffing meetings, staff development, and training.</p> </li><li> <p>Performs other duties and responsibilities as assigned.</p> </li><li> <p>Qualifications, Knowledge & Experience</p> </li><li> <p>Required Qualifications (Including any licensure, certification, education):</p> </li><li> <p>Licensed as a Registered Nurse and authorized by the State of Iowa to practice nursing.</p> </li><li> <p>Achievement of Baccalaureate degree in nursing within 6 years of hire if hired after January 1, 2014.</p> </li><li> <p>Two years of clinical experience in medical/surgical nursing, ICCU, or ED.</p> </li><li> <p>Basic Life Support (BLS) training, or within 90 days of hire and must maintain throughout employment.</p> </li><li> <p>Mandatory Reporter training or within 90 days of hire and must maintain throughout employment.</p> </li><li> <p>Organizational Requirements:</p> </li><li> <p>Maintain stroke education per regulatory requirements.</p> </li><li> <p>Preferred Qualifications:</p> </li><li> <p>None Specified</p> </li><li> <p>Required Knowledge, Skills & Experience:</p> </li><li> <p>Must be able to effectively communicate (verbally and in writing) in a professional and tactful manner with physicians, staff, patients, and/or their representatives.</p> </li><li> <p>Must maintain confidentiality of information.</p> </li><li> <p>Must possess critical thinking, problem solving and deductive reasoning skills.</p> </li><li> <p>Understanding and knowledge of medical terminology, ICD-10, and CPT codes</p> </li><li> <p>Internet usage skills</p> </li><li> <p>Knowledge of Microsoft related programs such as Word, Excel, Outlook, and Teams</p> </li><li> <p>Professional demeanor with strong administrative skills</p> </li><li> <p>Excellent written, verbal, and interpersonal communication skills.</p> </li><li> <p>Ability to multitask and maintain strong attention to detail</p> </li><li> <p>Ability to analyze and interpret information to make decisions within scope of job functions</p> </li><li> <p>Preferred Knowledge, Skills & Experience:</p> </li><li> <p>Previous utilization management or case management experience</p> </li><li> <p>Epic system experience</p> </li><li> <p>Experience working with medical insurance and prior authorizations</p> </li></ul>