Associate Clinical Finance Clearance Specialist RN or LPN (Precert Nurse)
JOB SUMMARY: Performs and documents pre-certification from insurance companies for all elective surgeries, with some guidance.
Obtains certification from insurance companies for all elective surgeries and admissions.
Assigns preliminary diagnosis and procedure codes when required by insurance review companies for authorization.
Contacts insurance review agencies to request authorization.
Handles problematic certification cases with relevant internal groups.
Performs extensive investigative and follow-up work on cases with precertification issues until the issue is resolved.
Documents certification process in the appropriate applications to facilitate accurate concurrent review, billing and reimbursement.
The responsibilities listed are a general overview of the position and additional duties may be assigned.
INSURANCE REGULATORY KNOWLEDGE (ADVANCED): - Demonstrates knowledge of the appropriate rules and regulations for insurance policies, claims, payment and coverage. Ability to interpret and explain rules and regulations that are ambiguous or unclear.
CUSTOMER SERVICE (INTERMEDIATE): - A continuing focus on the needs and requirements of customers, anticipating their needs, remaining sensitive to customers while performing services for them, responsive to customer needs.
DATA ENTRY (INTERMEDIATE): - The ability to transcribe information from the original source into an electronic system according to written and verbal instructions efficiently and accurately.
PROBLEM SOLVING (INTERMEDIATE): - Uses critical thinking and process improvement i.e. coaches and mentors development of problem statement, describes current state, identifies root causes, creates future state, coaches and mentors development of solutions and action plans with a sustainability plan. Applies appropriate tools to address issues.
CODING KNOWLEDGE (INTERMEDIATE): - Ability to assign and interpret ICD-10-CM/PCS coding classification systems and MS-DRG and APR-DRG prospective payment and severity systems.
Organizational Impact: Delivers job responsibilities that impact own job area/team with some guidance.
Problem Solving/ Complexity of work: Uses existing procedures, research and analysis to solve standard job related problems that may require some judgement.
Breadth of Knowledge: Requires subject matter knowledge within a professional area to meet job requirements.
Team Interaction: Individually contributes to project/ work teams.
Vanderbilt University Medical Center is home to Vanderbilt University Hospital, The Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Vanderbilt Psychiatric Hospital and the Vanderbilt Stallworth Rehabilitation Hospital. These hospitals experienced more than 61,000 inpatient admissions during fiscal year 2015. Vanderbilt’s adult and pediatric clinics treated nearly 2 million patients during this same period. Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt are recognized again this year by U.S. News & World Report’s Best Hospitals as among the nation’s best with 18 nationally ranked specialties. Vanderbilt University Medical Center is world renowned because of the innovation, work ethic and collegiality of its employees. From our health care advances to our compassionate care, Vanderbilt owes its accomplishments and reputation to staff and faculty who bring skill and drive and innovation to the medical center day after day. World-leading academic departments and comprehensive centers of excellence pursue scientific discoveries and transformational educational and clinical advances across the entire spectrum of health and disease.As t...he largest employer in middle Tennessee, we welcome those who are interested in ongoing development in a caring, culturally sensitive and professional atmosphere. Most of us spend so much of our lives at work, we want to be part of maintaining a workplace in which people support one another and encourage reaching for excellence. Many high-achieving employees stay at Vanderbilt because of the professional growth they experience and because of their appreciation of Vanderbilt’s benefits, public events and discussions, athletic opportunities, beautiful setting and, above all, sense of community and purpose.Vanderbilt and its employees share a set of mutual expectations that have been created with productivity, legality, fairness and safety always in mind. We believe that our investment in training and compensating employees multiplies in value when we enable individuals to deliver their best performance for the benefit of us all.