Clinical Pre-Service Nurse Coordinator - Days

Employment Type:

Full time

Shift:

Day Shift

Description:

Job Title:  Clinical Pre-Service Nurse Coordinator

Employment Type:  Full-Time

Shift:  Monday-Friday, 8:00 AM - 4:30 PM

Position Purpose

The Clinical Pre-Service Nurse Coordinator is directly responsible for reviewing pre/post service initial denials, securing escalated insurance authorizations, handling escalated medical necessity reviews and coordinating with Patient Access, Mid-Revenue Cycle and Patient Business Service (PBS) to identify opportunities for revenue optimization.

This role is supporting the Mid-Atlantic Region which includes:

Saint Francis Hospital, Wilmington, DE

Mercy Fitzgerald Hospital, Darby, PA

Nazareth Hospital, Philadelphia, PA

St. Mary Medical Center, Langhorne, PA

As a Clinical Pre-Service Nurse Coordinator you will:

• Works closely with Physician Providers to assure that the proposed intensity of service is in alignment with the severity of illness and accurately documented to support level of care determinations and required authorizations.

• Investigates denials and root causes and tracks and reports trends to remediate issues and assist with internal process improvement.

• Leverages clinical knowledge and standard procedures to ensure timely attention to denials as requested by PBS and assists in the research and application of regulatory policies to support administrative appeals.

• Communicates pertinent clinical information to Physicians, Medical Directors, and CFO, as indicated, regarding evaluation of medical appropriateness and/or payer determinations.

• Understands clinically complex medical situations and communicates appropriately with insurers as needed.

• Maintains a working knowledge of applicable Federal, State, and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

• Utilizes working knowledge of basic coding guidelines for medical necessity and insurance authorization escalations and/or denials.

• Awareness of how to navigate payer websites to occasionally validate insurance eligibility and authorizations.

• Familiarity with the construction of professional appeals in response to denied claims.

Minimum Qualifications:

• PA Registered Nurse or Licensed Vocational Nurse/Licensed Practical Nurse and graduate of an accredited school of nursing, plus at least two (2) years of nursing experience.

• Minimum two (2) years of pre-certification/prior approval clinical denial unit management experience.

• Demonstrated knowledge of patient access, revenue cycle and denial management functions. Certification and/or membership in AAPC, AHIMA, HFMA, AAHAM, NAHAM strongly preferred.

• Demonstrates an understanding of technical and clinical denials areas, such as: medical necessity, eligibility issues, no authorization. Working knowledge of medical terminology, and medical record coding experience (ICD-9, CPT, HCPCS) are highly desirable.

• Working knowledge of Epic Prelude and Resolute, including associated work queues is preferred.

• Strong organizational, task prioritization, resource management skills.

• Excellent written and oral communication & presentation skills.

• May be require travel up to 10% between locations within the Trinity Mid-Atlantic Region.

Position Highlights and Benefits:

• Comprehensive benefit packages, including medical, dental, vision, mental health, paid time off, 403B, education assistance and voluntary benefits (pet insurance, accident insurance, hospital indemnity and others) available from the first day of employment.

• Work/Life balance with flexible schedules.

• Free onsite parking.

• Our mission and core values are what drive each member of Trinity Health to support each other, communicate openly and respectfully while embracing a culture that nurtures a healing, safe environment for all.

• Referral Rewards Program

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.