Medical Necessity Analyst - Pre Services

SUMMARY:

Incumbent responsible for timely pre-services evaluation of physician-submitted clinical documentation supporting planned or elective procedures. Goal of evaluation: To ensure that patients’ planned healthcare services meet current published insurance payor guidelines yielding payment without claim denial. After prior authorization is obtained per current facility protocol, incumbent reviews surgical cases in established work queues then analyzes relevant healthcare documentation against current published payor guidelines to ensure it supports the meeting of medical necessity for the proposed procedure(s). If the healthcare documentation available in the EHR is insufficient, incumbent coordinates with involved healthcare providers and/or their designated associates to ensure the specific, required criteria have been fully documented prior to the delivery of planned healthcare service(s).

ESSENTIAL FUNCTIONS:

Exhibits excellence in customer service through appropriate attitude and interaction with all patients, visitors, providers, peers, and other staff. Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication.

Collaborates with providers and their office staff and other appropriate delegates to ensure documentation that establishes medical necessity is present and meets current published payor guidelines prior to planned healthcare services.

Analyzes and gathers clinical documentation prior to prospective healthcare delivery to patients utilizing EHRs.

Utilizes a variety of electronic verification tools and web-based resources to verify Common Procedural Terminology (CPT) codes and numerous current published insurance payor guidelines.

Identifies unmet medical necessity criteria within provided healthcare documentation which increases risk of non-payment to TMCH. Generates and issues targeted patient-and-case-specific addendum requests to the provider with recommendations for remediation, so documentation meets stated payor medical necessity requirements.

Documents clinical review summaries/findings in EHR.

Documents all other activity undertaken in the process of attempting to obtain/obtaining medical necessity documentation from providers in the EHR and/or any other appropriate locations.

Escalates concerns to department leadership as indicated (i.e., supervisor and manager).

Maintains appropriate organized confidential filing systems, records, and reports to ensure rapid retrieval of information by all team members and leadership.

May refer questions of a clinical nature to department leadership as well as Utilization Management RNs to ensure accuracy.

May attend meetings as a representative of the Pre-Services Medical Necessity team.

Coordinates with the Authorization team and other pre-services patient access entities within TMCH to confirm accuracy of supplied CPT codes and as otherwise needed.

Escalates questions or concerns regarding patient admission status related to proposed healthcare service(s) to appropriate individual or entity.

May train new peer analysts as well as assist less-experienced analysts in daily work.

Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards.

Performs other related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION:  High school diploma or general education degree (GED) required.

EXPERIENCE: Minimum of three (3) years of hospital and/or medical-surgical office experience. Must have documented experience working with either clinical healthcare documentation, medical coding, and/or billing systems. Healthcare Documentation Specialist/Professional, Medical Assistant, or comparable experience preferred.

LICENSURE OR CERTIFICATION: Certified Healthcare Documentation Specialist (CHDS), Certified Healthcare Documentation Professional (CHDP), or Certified Medical Assistant (CMA/MA) preferred but not required.

KNOWLEDGE, SKILLS, AND ABILITIES:

·         Excellent critical thinking skills; strong ability to apply common sense understanding to all aspects of daily duties.

·         Effective interpersonal skills utilizing proper communication etiquette when interacting in person, virtually, via email, and over the telephone.

·         Strong skill in reading and listening to ensure comprehension.

·         Excellent skill in both oral and written communication, including understanding and providing instructions as well as reading and writing correspondence in an appropriate and businesslike manner.

·         Ability to effectively and accurately present information to, as well as respond to, inquiries and complaints from all customers, which include providers, their representatives, and all employees of this organization.

·         Ability to effectively and accurately present information in one-on-one and small group situations.

·         Ability to read and analyze documents such as clinical healthcare documentation, current published payor guidelines, and government regulations.

·         Intermediate to advanced knowledge of medical terminology, surgical procedures, and imaging, as well as anatomic systems and medical-surgical specialties.

·         Ability to use an extensive array of professional reference materials in both printed and electronic format for research and reference.

·         Ability to understand and compare information entered into the medical record by various sources, and ability to accurately determine that the information is consistent and appropriate to meet current published payor guidelines.

·         Ability to maintain composure while multi-tasking (performing more than one task at a time and/or quickly switching back and forth between tasks) as well as endure frequent interruptions at the same as working under pressure of time constraints.

·         Ability to work independently with minimal supervision.

·         Ability to concentrate and pay attention to detail, yielding results with a high degree of accuracy.

·         Ability to understand and apply relevant medicolegal concepts such as confidentiality.

·         Ability to assist other staff effectively and patiently when needed.

·         Ability to "triage" competing tasks while meeting department, facility, and personal productivity and quality benchmarks.

·         Knowledge and use of Microsoft applications, EHR software, the internet, and various other applications as well as general computer, keyboard, and mouse usage. Must have basic ability to troubleshoot computer, internet, and software issues.

·         Knowledge of CPT codes is helpful.

·         Knowledge of regulations relating to commercial insurance programs as well as Federal healthcare programs such as Medicare and Medicaid (AHCCCS) preferred.