拒赔预防专员，临床人员 PRN
Denials Prevention Specialist, Clinician PRN
Datavant 是一家数据平台公司，是全球医疗数据交换领域的领导者。我们的愿景是让每一次医疗决策都能在正确的时间、以正确的形式获得正确的数据。
我们的平台依托美国最大、最多样化的医疗数据网络，使数据安全、可访问且可用，从而帮助做出更好的医疗决策。Datavant 被全球领先的生命科学公司、政府机构以及提供和支付医疗护理的各方所信赖。
加入 Datavant，您将加入一个高绩效、价值观驱动的团队。我们共同致力于用技术驱动的解决方案应对医疗领域最复杂的问题。Datavant 员工带来了多样化的专业、教育和生活经验，以实现我们对医疗健康的远大愿景。
Denial Prevention Specialist 的职责是有效捍卫对可用医疗服务的使用，审查入院是否符合医疗必要性，以及住院患者是否需要继续住院或转至其他护理级别。使用国家认可的医疗必要性标准和护理规范，结合临床知识和专业技能，成功完成工作。
*****理想的候选人应是持有执照的护士或注册护士，熟悉 DRG 降级拒赔和住院入院上诉撰写，有临床标准资源和保险公司指南的经验。*******
您将：
- 通过准确判断及时进行转诊/上诉决定
- 在使用 Milliman Care Guidelines 或 Interqual 的情况下工作
- 选择合适的信件内容来撰写上诉信，识别需要提交给医疗总监审核的转诊
- 选择适当的首选和签约供应商
- 正确识别资格和医疗计划
- 按照设施或 CIOX Health 标准规定的 TAT 时间要求保持合规
- 在需要时直接与供应商和医保医疗总监合作，促进及时授权和/或拒赔撤销
- 保持所有文件、文档和记录的完整保密性
- 达到或超过生产率和质量指标
- 参加所有强制性会议和培训
- 完成与职位职能相关的其他所有工作职责，根据管理层的指派执行
查看英文原文
Datavant is a data platform company and the world’s leader in health data exchange. Our vision is that every healthcare decision is powered by the right data, at the right time, in the right format.
Our platform is powered by the largest, most diverse health data network in the U.S., enabling data to be secure, accessible and usable to inform better health decisions. Datavant is trusted by the world’s leading life sciences companies, government agencies, and those who deliver and pay for care.
By joining Datavant today, you’re stepping onto a high-performing, values-driven team. Together, we’re rising to the challenge of tackling some of healthcare’s most complex problems with technology-forward solutions. Datavanters bring a diversity of professional, educational and life experiences to realize our bold vision for healthcare.
The purpose of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of admissions for medical necessity and necessity of continued stay in the inpatient patient care setting and/or discharge to an alternative level of care. Using nationally recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully.
*****Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in DRG downgrade denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payor guidelines.*******
You will:
- Provide timely referral/appeal determination by accurate
- Work under the usage of the Milliman Care Guidelines and or Interqual
- Select appropriate letter language to author appeal letter Identification of referrals to the medical director for review
- Select appropriate preferred and contracted providers
- Provide proper identification of eligibility and healthcare plans
- Maintain compliance in turnaround time requirements as mandated by the TAT Standards of the facility and/or CIOX Health Standards
- Work directly with the provider(s) and health plan Medical Director as needed to facilitate timely authorizations and/or denial reversals
- Maintain and keeps in total confidence, all files, documents and records
- Meets or exceeds production and quality metrics
- Attend all mandatory meetings and trainings All other job-related duties as it relates to job function as delegated by management
*****Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in DRG downgrade denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payor guidelines.******
What you will bring to the table:
- Two (2) years managed care experience in UM/CM/CDI Department preferred
- Knowledge of CMS, State Regulations, URAC and NCQA preferred
- ICD10 and CPT coding a plus
- Experienced computer skills, Word, Excel, Outlook, experience working in a health plan medical management documentation system a plus.
Minimum Education: LVN/LPN
- Preferred Education: BA or BS in Nursing, experience preferred to perform
- Minimum Experience: 3 to 5 years acute care experience
- 2 years Health Plan or Acute Care UR/CM
- Preferred Experience: 5 years acute care or health plan UR/CM with 1 year ICU/ER
We are committed to building a diverse team of Datavanters who are all responsible for stewarding a high-performance culture in which all Datavanters belong and thrive. We are proud to be an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, or other legally protected status.
Our compensation philosophy is to be externally competitive, internally fair, and not win or lose on compensation. Salary ranges for this position are developed with the support of benchmarks and industry best practices.
We’re building a high-growth, high-autonomy culture. We rely less on job titles and more on cultivating an environment where anyone can contribute, the best ideas win, and personal growth is driven by expanding impact. The range posted is for a given job title, which can include multiple levels. Individual rates for the same job title may differ based on their level, responsibilities, skills, and experience for a specific job. The estimated salary range for this role is $22 - $45
Pay ranges for this job title may differ based on location, responsibilities, skills, experience, and other requirements of the role.
The estimated base pay range per hour for this role is:
$22$45 USD
To ensure the safety of patients and staff, many of our clients require post-offer health screenings and proof and/or completion of various vaccinations such as the flu shot, Tdap, COVID-19, etc. Any requests to be exempted from these requirements will be reviewed by Datavant Human Resources and determined on a case-by-case basis. Depending on the state in which you will be working, exemptions may be available on the basis of disability, medical contraindications to the vaccine or any of its components, pregnancy or pregnancy-related medical conditions, and/or religion.
This job is not eligible for employment sponsorship.
Datavant is committed to a work environment free from job discrimination. We are proud to be an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, or other legally protected status. To learn more about our commitment, please review our EEO Commitment Statement here. Know Your Rights, explore the resources available through the EEOC for more information regarding your legal rights and protections. In addition, Datavant does not and will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay.
At the end of this application, you will find a set of voluntary demographic questions. If you choose to respond, your answers will be anonymous and will help us identify areas for improvement in our recruitment process. (We can only see aggregate responses, not individual ones. In fact, we aren’t even able to see whether you’ve responded.) Responding is entirely optional and will not affect your application or hiring process in any way.
Datavant is committed to working with and providing reasonable accommodations to individuals with physical and mental disabilities. If you need an accommodation while seeking employment, please request it here, by selecting the ‘Interview Accommodation Request’ category. You will need your requisition ID when submitting your request, you can find instructions for locating it here. Requests for reasonable accommodations will be reviewed on a case-by-case basis.
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Originally posted on Himalayas