Director of Utilization Review & RCM:

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Team Leadership Developer:

• EMR-PM-Clearing House-Payer Onboarding Trainer & Supervisor

• Utilization Management Optimization, Customization & Oversight

• Collection Team Build Out Specialist: Level 3 Peer Panel Review Leader

• RCM Billing and Collection Reimbursement AP/AR Audit Tool Developer

• ICD-10 Crosswalk Optimization & Customization: Dx-CPT-HCPCS-MOD Developer

Workflow Job Description Competencies:

• Advocates for the Most Comprehensive and Integrated Patient-Provider Access to Practice Specific Service Lines for All Staff and Treatment Team Providers

• Promotes Effective Utilization Resources for Patients to Provide the Highest Standard and Quality of Care and Highest Reimbursements

• Collaborates with Treatment Team Daily Regarding: VOBs, Auths/Certs and Continued Stay Criteria

• Coordinates with Level 1-3 Payer Case Managers and Level 1-3 Peer Review in the Appeals Process

• Maintains Accurate Daily-Weekly-Monthly Statistical Reports then Prepares Proper Drill Down Documentation of Findings

• Communicates, Educates and Supervises Payer Provider Manual Requirements to all Staff Providers

• Maintains Proper Documentation and Notation Through Daily Chart Audits for all Related UR activities for All Patients and Providers

• Assures and Completes Peer Panel Approvals for All Appeal Collections and Overseas All Concurrent Reviews for Accuracy, Efficiency and Efficacy

• Provides Intel Updates Regarding all Patient ti Staff Workflows for Intakes and Discharges and Reporting into EMR-PM Documentation Logs

• Prepares Daily, Weekly, Monthly, Quarterly and Annual Audit Reports and Minutes Agendas for Leadership

• Reviews Admission, Intake and Discharges Processes as well as any Incidents and Emergent Issues

• Reviews Claim Data Daily and Updates Reimbursement and Denial Statistics for all Current and Aging AR from EDI-ERA Data

• Initiates Immediate Claims Appeals within 24-48 hours of Denials and Reconciles AP/AR Reports for All Payments and Reimbursements

• Consults with Office Administration, Billing and Leadership to Clarify EOB and EOP Remittance Data for RCM Optimization

• Ensures and Supports Daily Team Workflows from Upfront Insurance Pre-Certification Process through the Concurrent UR Processes

• Provides Accurate and Detailed Medical Necessity Intel to Payer Peer Review Panels to Maximize and Increase Revenue Stream

• Trains and Supervises All Staff and Providers for Building and Maintaining Proper Medical and Clinical Necessity to Capture All Revenue Opportunities

• Advocates for Patient High Acuity Placement in the Appropriate Level of Care with the Appropriate Days

• Establishes and Manages Positive Effective Payer Relationships to Maximize Length of Stay and Level of Visit for All Levels of Care

• Analyzes and Identifies Any and All Revenue Disparities and Turns Then into Positive Revenue Opportunities