Job Description

Responsible for coordinating and monitoring the authorization and denials management processes. Serves as a liaison between ordering and referring physicians, insurors, patient financial services, case management, HIM, PAS, surgery and diagnostic departments, and patients while evaluating clinical criteria to obtain authorization to secure successful payment for procedure(s) performed within the MLH system. Monitors and reports identified certification and payer issues, researches denials to identify patterns, then educates physician practice staff to assure successful claims submission and payment. Models appropriate behavior as exemplified in MLH Mission, Vision and Values. Manages Authorization process to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to prior authorization requests. Identifies, monitors and reports problematic areas in the certification process, which may impact registration, billing, and reimbursement. Manages and researches denials. Coordinates denials management with physician practices & throughout MLH. Actively participates in Methodist CIP efforts; identifies and communicates areas for improvement in ongoing efforts for quality care; assists in gathering, analyzing, and presenting data in the assigned populations. Demonstrates initiative in identifying and pursuing opportunities for self-improvement and enhancement of professional competency. Demonstrates effective customer relation skills, promotes a positive work environment, and contributes to the overall team effort. Establishes a good working relationship with physicians, clients, and other members of the health care team. Understands, applies, and supports department/hospital policies, procedures, and standards. Performs other job functions as requested or assigned. Education/Formal Training Requirements: Associate's Degree Nursing- RN, Bachelor's Degree Nursing- RN. Work Experience Requirements: Authorization or Denials Management, Care Coordination, Case Management, 5-7 years Clinical nursing. Licenses and Certifications Requirements: Case Manager - The Commission for Case Manager Certification, Registered Nurse Arkansas - Arkansas State Board of Nursing, Registered Nurse Mississippi - Mississippi Board of Nursing, Registered Nurse Tennessee - Tennessee Board of Nursing. Knowledge, Skills and Abilities: Positive working relationship and excellent interpersonal skills in working with physicians required. Excellent written and verbal communication skills. Ability to plan and schedule tasks and to maintain control of own work flow. General PC skills. Ability to communicate information to groups of people in an educational setting. Effective interpersonal relationship skills. Physical Demands: Non-invasive patient contact. Must be able to read, write, and communicate both orally and in writing to individuals in the healthcare field. Normal or corrected-to-normal vision. Must have good balance and coordination.

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