Registered Nurse – Financial Clearance Specialist

Title: Registered Nurse – Financial Clearance Specialist

Job Summary:

Responsible for obtaining authorizations for scheduled Oncology services, and other medical specialties as needed. Reviews medical records and prepares clinical reviews for medical necessity and authorization. Responsible for facilitating the denial and appeal process.

Key Position Details:

Work from home.

Work hours are 730a-4p with flexibility on work demands.

Job Description:

Job Requirements

• Bachelor’s degree in Nursing required
• 2 to 5 years experience in an acute hospital or medical clinic setting required
• 2 to 5 years health insurance authorization experience preferred and
• 2 to 5 years experience using InterQual, MCG, or other clinical criteria preferred
• Licensed Registered Nurse – MN Board of Nursing required upon hire

Principle Responsibilities

• Ensure services/procedures are appropriate and necessary per health benefit plans.
  • Assess clinical data from medical records to obtain authorization for scheduled services.
  • Abstract and submit clinical data from medical records to insurance payers.
  • Utilize clinical screening criteria and reviews insurance payer medical policies to ensure patients meet medical necessity for scheduled services.
  • Assure the medical record has the proper physician clinical documentation.
  • Monitor for continued authorization, communicates results and opportunities to nurses, physicians, finance, case managers, and payers.
• Facilitate denials and appeals process.
  • Evaluate potential denials or payment issues and initiates communication with physician or clinician regarding next steps.
  • Prepare and facilitates appeals for denied claims.
  • Facilitate peer to peer requests between the ordering physician, and the payer physician.
  • Other duties as assigned.