Medical Necessity Specialist
Minimum Entry Level Qualifications:
- Experience and/or level of competency:
- Experience Required: 3 + years of healthcare-related experience.
- High School graduate or equivalent required.
- College degree preferred.
- Prior CDM or charge capture experience required.
- Academic Preparation:
- High School or GED
- Preferred - applicable clinical or professional certifications and licenses such as LVN, Certified Outpatient Coder (COC), Certified Professional Coder (CPC), Certified Coding Specialist (CCS) highly desirable.
Under the general supervision of the Revenue Cycle Leadership, a Medical Necessity Specialist is responsible for maintaining a positive, helpful attitude and approach in providing excellent customer service to all customers which include; patients, clients, referral sources, physicians, and sales representatives in verifying benefits and coverage with the health plan, sending out and obtaining medical necessity documentations in a timely manner.
- Responsible for creating, sending out and/or obtaining all medical necessity documentations in a timely manner and log information in the system.
- Maintains and updates all medical necessity information in the system such as patient information, payer changes, and other information to support billing process.
- Communicates with physicians offices, medical groups, MSO, and health plans on a daily basis for medical necessity documentation and for the continuation of patient equipment.
- Communicates to Lead or Supervisor or Manager regarding progress, updates, problems, error trends, new findings, inaccurate or untimely claim submission, and others in a timely manner.
- Maintains a daily follow-up system and checks the starting & expiring dates of medical necessity documentations.
- Submits appropriate documentation such as prescription, labs results, medical justification, authorization, eligibility, and others as necessary and applicable in a timely manner.
- Works on Hold Revenue report, group projects, goals and renewal process.
- Maintains accurate and complete daily productivity report.
- Performs other duties as assigned.
- Remains knowledgeable on product and insurance coverage issues in order to inform
- patients of copays and other benefit information
- Attends all departmental meetings, company meetings, and in-services
- Reports to work daily and is ready to work at the scheduled start time
- Performs any other duties that may be requested by supervisor or management
- To remain knowledgeable to date on all products, guidelines and insurance coverage trends
- Maintain a professional safe and clean work environment.
- Understand and adheres to all of VVRMC company policies.
- Perform all other duties as assigned and required
- Must meet minimum of monthly goals
Knowledge, Skills and Abilities:
- Analytical/Critical thinking
- Problem solving
- Knowledge and application of ICD-10-CM, HCPCS, and CPT-4 classification systems
- Excellent written and verbal communication skills
- Competent with computers, Microsoft Office, Electronic Medical Records, and various electronic coding resources
- Adheres to dress code; appearance is clean and neat.
- Completes annual educational requirements.
- Maintains regulatory requirements including all state, federal and CIHQ regulations related to the HIM Department and, as appropriate, to the facility.
- Reports to work on time and as scheduled; completes work within designated time.
- Wears identification on duty; uses computerized punch time system correctly.
- Attends annual review and performs departmental in-services.
- Holds staff meetings, provides minutes of the meeting to HIM Department staff members.
- Attends committee and management meetings as appropriate.
- Ensures patient confidentiality and privacy at all times.
- Resolves personnel concerns at the department level, utilizing the grievance process as required.
- Ensures compliance with policies and procedures regarding department operations, fire, and safety and infection control.
- Effectively and consistently communicates administrative directives to personnel and encourages interactive departmental meetings and discussions.
- Represents the organization in a positive and professional manner.
- Complies with all organizational policies regarding ethical business practices.
- Communicates the mission, ethics and goals of the facility, as well as the focus statement of the department.