"Provider Relations Specialist RN Full Time Days" AdventHealth SC Connerton
Location Address: 9441 Health Center Drive Land O' Lakes, Florida 34637
Top Reasons To Work At AdventHealth SC Connerton
Specialty hospital for medically complex patients
Pulmonary and Vapotherm Center of Excellence
Staff consists of all Registered Respiratory Therapist, 65% BSN or above RNâ™s, Current staff certifications include CCRN, PCCN, CNML, WCNC, NEA-BC, and RN-BC
Onsite BSN completion program partnership with South University with staff discounted rate
Simulation Lab and Clinical Transition Pilot Program
Full Time Days
You Will Be Responsible For:
Handles all telephone duties and responsibilities.
Follows the Workflow Process for initiating and completing patient authorizations.
Obtains timely authorization of all patients requiring pre-certification.
Ensures all policies governing commercial pre-certification and authorization are followed to minimize financial risk.
Evaluates Commercial benefits as verified by the CBO
Reviews Medicare benefits through VisionShare and Common Working File and accurately accounts for whether the patient has traditional Medicare or a Medicare Advantage plan.
Payor Information System to secure Billing and Reimbursement forms and Hospital Contracts to review accommodation codes.
Applies correct accommodation code through application of the contracted rate per the contract.
Communicates daily with Director of Business Development with authorization status.
Maintains accurate accounting of all referrals for authorization approvals and denials on the designated Daily Productivity Worksheet/Log.
Maintains thorough and complete notes in Cerner UR, notes ensuring that the Case Manager has all information necessary to follow up with continued stay review on each commercial patient.
Verifies Patient Information and Online coverage on Patient Accounts (Pre-Registration)
Contacts or communicates with the patient and verifies or gathers all demographic, guarantor, employment, insurance, coordination of insurance benefits and provider information.
Contacts providerâ™s office to verify or obtain any missing medical, procedure, and diagnosis information
Enters verification information on individual patient accounts. This includes pre-registration, pre-admits and direct admits.
Reviews each established inpatient and outpatient account to ensure billing information is complete.
Refers cases of inadequate or un-verifiable insurance coverage to the Insurance Verifiers.
Enters all information regarding pre-certification, authorizations and Length of Stay information in financial systems.
Completes all other duties as assigned.
May cover for Admissions Coordinator and/or Clinical Liaison, as needed.
Case Management :
Strive to provide excellence in service to hospital staff, patients and families.
Demonstrate care for one another and respect for each personâ™s unique contributions, provides utilization review care that is non-judgmental and non-discriminatory
Assess appropriateness of setting as indicated for medical necessity according to the approved InterQual ISD criteria. Initial and concurrent clinical reviews contain needed elements to sufficiently support
Works cases denied by insurance and assist to submit appeals in conjunction with FH Tampa CBO staff
Utilizes InterQualÂ®ISD & or Milliman criteria to ensure appropriate level of care settings
Passes Annual Inter-Rater reliability testing for InterQualÂ®
Ensures appropriate referral of cases to EHR for second level review.
Identifies and updates current information on community resources.
Completes annual mandatory education, attend and contributes to 95% of staff meetings.
What You Will Need:
RN from diploma, Associate or Bachelorâ™s Degree
1 Year Bedside RN in a complex patient care environment (ICU/PCU preferred)
1 Year direct experience with third party reimbursement
1 Year experience in case management in an acute care environment.
1 Year experience with precertification of hospital patients
1 Year experience working with insurance and/or in a medical office setting
1 Year accounts receivables billing and/or collections experience
Experience with InterQual preferred.
Case Management Certification
The above statements reflect the general duties and responsibilities necessary to describe the principal function
This position has three scopes of responsibility:
Pre-Certification: Manages the pre-certification and prior authorization of referrals scheduled for admission to Florida Hospital Connerton Long Term Acute Care.
Insurance Verification: Responsible for the accurate and timely verification of patientsâ™ insurance coverage for all admissions.
Utilization Review: Assures medical necessity review criteria as mandated by the QIO is implemented for all admissions and continued stays. Completes InterQual reviews for continued stay review and shares with the payer as per request. Advises Case Manager and Director of Business Development of any patients no longer meeting criteria or denials of continued stay immediately.
AdventHealth Greater Orlando (formerly Florida Hospital) is one of the largest faith-based health care providers in the United States. For 150 years, we have carried on a tradition of providing whole-person care that not only addresses patients' physical ailments, but also supports their emotional and spiritual well-being. We demonstrate the same level of compassion and care for our employees as well, doing all that we can to help them realize their full potential – both personally and professionally.
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