Centauri Health Solutions Inc
Utilization Review Nurse, Authorization & Appeals
Centauri Health Solutions Inc, Atlanta, Georgia, United States, 30383
Centauri Health Solutions provides technology and technology-enabled services to payors and providers across all healthcare programs, including Medicare, Medicaid, Commercial and Exchange. In partnership with our clients, we improve the lives and health outcomes of the members and patients we touch through compassionate outreach, sophisticated analytics, clinical data exchange capabilities, and data-driven solutions. Our solutions directly address complex problems such as uncompensated care within health systems; appropriate, risk-adjusted revenue for specialized sub-populations; and improve access to and quality of care measurement. Headquartered in Scottsdale, Ariz., Centauri Health Solutions employs 1700 dedicated associates across the country. Centauri has made the prestigious Inc. 5000 list since 2019, as well as the 2020 Deloitte Technology Fast 500™ list of the fastest-growing companies in the U.S. For more information, visit www.centaurihs.com.
Role Summary:
Coordinates the preparation of authorizations, treatment authorization requests and appeals including obtaining medical records, submission of initial Authorization or Treatment Authorization Request and filing any appeal(s) that may be necessary to maximize the number of billing days allowed by the payer. Consistently communicates the status to facility and team as appropriate. Must demonstrate the ability to multi-task job responsibilities and remain focused on these duties for long periods of time.
Role Responsibilities:
Reviews medical records and prepares authorizations as appropriate. Reviews account denials and medical records and prepares appeals as appropriate. Monitors and progresses all pending authorizations and appeals until resolution. Checks third-party payer eligibility to ensure the information provided matches the database information. Communicates authorization and appeal status to assigned facilities and onsite Centauri staff. Submits and/or mails the retro-authorization form and supporting documentation to payer program. Updates accounts based on balance and updates systems as work is completed. Prepares daily, weekly, and monthly reports for facilities and other departments when appropriate. Communicates issues and project status to management as needed. Performs follow-up on initial denials received from payors on retrospective clinical reviews by first level of appeal submission. Ensure Diagnosis and Procedure codes align with services performed and communicate discrepancies to appropriate contacts per workflow process. Follows suspense dates in internal system to update account status on the authorizations or appeals on a timely basis. Handles and manages multiple duties and remain focused on the completion of these essential duties for long periods of time. Interacts with key hospital contacts to provide updates of account progress and inform of our production and success rates. Works collegially and professionally with all internal and external staff. Attends client and internal meetings as required. Updates and maintains authorization log for accuracy and to report status of authorization accounts to clients. Ensures HIPAA compliance in all business practices. Reports incidents on a timely basis. Perform other related tasks as assigned by supervisor or manager and maintains department productivity and quality measures. Attends regular staff meetings, always conducts self in a professional manner, and completes assigned work objectives and projects in a timely manner. Other duties as assigned. Role Requirements:
LPN or RN Required 1-3 years of experience in medical billing, insurance verification, or prior authorizations Proficiency in medical terminology and ICD/CPT coding Bilingual Spanish Preferred Experience working with healthcare providers, insurance companies, or electronic medical records (EMR) systems is highly valued. Familiarity with Medicare, Medicaid, and commercial insurance guidelines Knowledge of UM principles and practices, involving medical and behavioral case management, disease management, utilization and pharmaceutical management desired. Skilled with clinical knowledge and experience in the treatment of human injuries, diseases, and deformities including symptoms, treatment alternatives, drug properties and interactions, behavioral health conditions and preventive health guidelines. Knowledge of applicable state, and federal regulations. In-depth knowledge of InterQual and other references for length of stay and medical necessity determinations. Excellent follow through skills during the application process to ensure payment is a requirement of the position. Must develop and/or possess a strong understanding of all reimbursement programs used in the state or area with which they may work accounts or conduct business. Strong Literacy (grammar, spelling, math) Proficient in use of Microsoft Products (Word, Excel, Outlook, Windows) Technology focused
We believe strongly in providing employees a rewarding work environment in which to grow, excel and achieve personal as well as professional goals. We offer our employees competitive compensation and a comprehensive benefits package that includes generous paid time off, a matching 401(k) program, tuition reimbursement, annual salary reviews, a comprehensive health plan, the opportunity to participate in volunteer activities on company time, and development opportunities. This position is bonus eligible in accordance with the terms of the Company's plan.
Centauri currently maintains a policy that requires several in-person and hybrid office workers to be fully vaccinated. New employees in the mentioned categories may require proof of vaccination by their start date. The Company is an equal opportunity employer and will provide reasonable accommodation to those unable to be vaccinated where it is not an undue hardship to the company to do so as provided under federal, state, and local law.
Factors which may affect starting pay within this range may include geography/market, skills, education, experience and other qualifications of the successful candidate.
This position is bonus eligible in accordance with the terms of the Company's plan.
Role Summary:
Coordinates the preparation of authorizations, treatment authorization requests and appeals including obtaining medical records, submission of initial Authorization or Treatment Authorization Request and filing any appeal(s) that may be necessary to maximize the number of billing days allowed by the payer. Consistently communicates the status to facility and team as appropriate. Must demonstrate the ability to multi-task job responsibilities and remain focused on these duties for long periods of time.
Role Responsibilities:
Reviews medical records and prepares authorizations as appropriate. Reviews account denials and medical records and prepares appeals as appropriate. Monitors and progresses all pending authorizations and appeals until resolution. Checks third-party payer eligibility to ensure the information provided matches the database information. Communicates authorization and appeal status to assigned facilities and onsite Centauri staff. Submits and/or mails the retro-authorization form and supporting documentation to payer program. Updates accounts based on balance and updates systems as work is completed. Prepares daily, weekly, and monthly reports for facilities and other departments when appropriate. Communicates issues and project status to management as needed. Performs follow-up on initial denials received from payors on retrospective clinical reviews by first level of appeal submission. Ensure Diagnosis and Procedure codes align with services performed and communicate discrepancies to appropriate contacts per workflow process. Follows suspense dates in internal system to update account status on the authorizations or appeals on a timely basis. Handles and manages multiple duties and remain focused on the completion of these essential duties for long periods of time. Interacts with key hospital contacts to provide updates of account progress and inform of our production and success rates. Works collegially and professionally with all internal and external staff. Attends client and internal meetings as required. Updates and maintains authorization log for accuracy and to report status of authorization accounts to clients. Ensures HIPAA compliance in all business practices. Reports incidents on a timely basis. Perform other related tasks as assigned by supervisor or manager and maintains department productivity and quality measures. Attends regular staff meetings, always conducts self in a professional manner, and completes assigned work objectives and projects in a timely manner. Other duties as assigned. Role Requirements:
LPN or RN Required 1-3 years of experience in medical billing, insurance verification, or prior authorizations Proficiency in medical terminology and ICD/CPT coding Bilingual Spanish Preferred Experience working with healthcare providers, insurance companies, or electronic medical records (EMR) systems is highly valued. Familiarity with Medicare, Medicaid, and commercial insurance guidelines Knowledge of UM principles and practices, involving medical and behavioral case management, disease management, utilization and pharmaceutical management desired. Skilled with clinical knowledge and experience in the treatment of human injuries, diseases, and deformities including symptoms, treatment alternatives, drug properties and interactions, behavioral health conditions and preventive health guidelines. Knowledge of applicable state, and federal regulations. In-depth knowledge of InterQual and other references for length of stay and medical necessity determinations. Excellent follow through skills during the application process to ensure payment is a requirement of the position. Must develop and/or possess a strong understanding of all reimbursement programs used in the state or area with which they may work accounts or conduct business. Strong Literacy (grammar, spelling, math) Proficient in use of Microsoft Products (Word, Excel, Outlook, Windows) Technology focused
We believe strongly in providing employees a rewarding work environment in which to grow, excel and achieve personal as well as professional goals. We offer our employees competitive compensation and a comprehensive benefits package that includes generous paid time off, a matching 401(k) program, tuition reimbursement, annual salary reviews, a comprehensive health plan, the opportunity to participate in volunteer activities on company time, and development opportunities. This position is bonus eligible in accordance with the terms of the Company's plan.
Centauri currently maintains a policy that requires several in-person and hybrid office workers to be fully vaccinated. New employees in the mentioned categories may require proof of vaccination by their start date. The Company is an equal opportunity employer and will provide reasonable accommodation to those unable to be vaccinated where it is not an undue hardship to the company to do so as provided under federal, state, and local law.
Factors which may affect starting pay within this range may include geography/market, skills, education, experience and other qualifications of the successful candidate.
This position is bonus eligible in accordance with the terms of the Company's plan.