This position provides opportunities to work in a fast-paced, challenging, diverse and rewarding environment. As an employee you will enjoy generous benefits and work/life programs. For detailed information on Benefits for this position, click here.
UW Medicine's mission is to improve the health of the public by advancing medical knowledge, providing outstanding primary and specialty care to the people of the region, and preparing tomorrow's physicians, scientists and other health professionals. UW Medicine owns or operates Harborview Medical Center, Northwest Hospital & Medical Center, Valley Medical Center, UW Medical Center, a network of UW Medicine Neighborhood Clinics that provide primary care, UW Physicians, UW School of Medicine, Airlift Northwest, and other owned, operated or affiliated entities as appropriate. In addition, UW Medicine shares in the ownership and governance of Children's University Medical Group and Seattle Cancer Care Alliance a partnership among UW Medicine, Fred Hutchinson Cancer Research, and Seattle Children's. Our staff not only enjoys outstanding benefits and professional growth opportunities, but also an environment noted for diversity, community involvement, intellectual excitement, artistic pursuits, and natural beauty.
The Financial Access Clinical Compliance Analyst (RN) acts as the clinical liason between the Financial Access Clearance Team and the University of Washington Medical Center and Harborview Medical Center administrator and clinical departments.
This position will also assist non-clinical staff with interpreting payer and 3rd party administorys with regards to clinicall-based forms required in the prior authorization and pre-determination phase of financial clearance.
In addition, the position will provide analysis of claim denials related to Patient Access responsible reasons during the prior authorization phase and after claim submission to identify areas of process improvement in order to achieve denial reduction and increased revenue. This position is also responsible to independently write and send medical necessity justification letters, along with researching and supplying additional supportive documentation, and will actively engage in peer-to-peer discussions with external payors and third party administrators on behalf of the UW Medicine.
Position requires prioritizing hospital claim (external) audits and denials by weighing multiple factors such as dollars at risk, payer appeal deadlines, research time involved, volume of claims, pre-billed status, and data needed from other internal departments. Work is done independently with limited oversight, flexibility in determining where time and resources are spent; progress and outcomes are tracked and reported in written appeals, claim databases, project spreadsheets, and regular fiscal and resource reports to UW Medicine Administration, demonstrating position accountability. Clinical and medical record analysis is provided as a resource to departments including Patient Financial Services, Finance, Contracting, Revenue Cycle Management, Compliance, Risk Management and the Attorney General's office; patient confidentiality is a priority. Often there is a need to anticipate the data to be extracted and the format in which findings are reported, in order to effectively provide upper management an analysis of audit/denial activity and appeal interventions. This position uniquely involves the review of services and devices denied during the pre-service period of authorization, the analysis of any subsequent denials by payers, and the opportunity to provide feedback to front-end clinical, registration, coding, and charge departments for the purposes of increasing the accuracy of medical record documentation, promoting compliance with coding and billing regulations, identifying contractual issues, improving internal processes and maximizing charge reimbursement and successful prior authorizations and pre-determinations. Critical thinking and strategy are required for a broad basis in responding to audits. Decisions made in appeals and agreements affect not only individual claims but also may set a reimbursement precedent with payers, affecting the volume and fiscal risk of future external audits. Flexibility is necessary as audits and requests frequently come with short notice, appeal deadlines, high dollars-at-risk, and require reprioritizing projects. Diplomacy, assertiveness, and a team approach are needed in working with a broad range of internal, external, administrative, and clinical personnel.
Key to this position is it's support of fiscal solvency for the University and UW Medicine. By preventing and appealing payer denials of service both pre- and post claim reimbursement, accountability of County, State, and Federal dollars is fostered and monetary funds for patient care are increased. Priorities of minimizing fiscal risk in audits, identifying causes of internal revenue loss, and analyzing compliance with regulatory guidelines all have a positive impact to the University. This position has independent discretion in representating the University of Washington policies and procedures and UW Medicine's reimbursement positions, in both verbal and written content, to both government and commercial payers and third-party agencies. Through participation in interdepartment committees and projects, contribution to improved processes and the analysis, revision, and formulation of UW Medicine policies is promoted.
Analysis of external pre-authorization and pre-determination audits and claim denials to determine appropriate action and response. Denials are reviewed for potential scheduling, authorization submission and coding errors, medical records are researched for supportive documentation, clinical departments may be consulted for detail on procedures and care provided, and regulatory coding and billing guidelines are referenced. For claims and pre-authorization and pre-determination requests that appear to have been inappropriately denied, formal appeals are written and submitted to payers and their agents, including supportive records which often require detailed preparation in order to match charges with the substantiating documentation. Communication with external auditors and payer representatives is pursued in an effort to mutually resolve all authorization issues and attain the desired authorization and reimbursements. When scheduling and authorization submission errors are found, follow-up occurs with internal departments to foster process improvement, claim adjustments are made in cooperation with Patient Financial Services billers, and any potential disclosure issues are reported to UW Medicine Compliance. Process Improvement work and conducting coordination efforts with internal and external departments, to include external organizations affiliated with UW Medicine to correct process errors as discovered and identified during audits and analysis.
Internal audits and projects (Epic, 3M, Mosiac, Max)
Act as resource/liason between University of Washington Medical Center and Harborview Medical Center administrative and clinical departments, including medical record and claim analysis and data extraction and successful prior authorization and pre-determination results.
Monitoring and reporting audit and reimbursement findings, dollars at risk, payer denial trends, and resource consumption. Occasional project presentations may be given in administrative meetings.
Research changes in payer policies, reimbursementand, and billing regulations for fiscal impact and potential appeal and/or charges in internal practices.
BA in Nursing - At least 4 years experience in clinical inpatient hospital and outpatient ambulatory nursing and medical/insurance regulations and payer requirements related to authorizations. RN License. RN license must be current. Proficiency in computer software programs including Microsoft Word, Excel, and Power Point.
Experience writing and submitting letters of medical necessity, training / assisting non-clinical personnel in interpreting clinical documentation for the purpose of authorization submission, root cause analysis of denials, process improvement training and / or instruction.
Key to this position are the ability to prioritize projects, work independently, communicate effectively, make high-level decisions regarding audit outcomes and the appeal process, and initiate involvement of other departments as needed.
CONDITIONS OF EMPLOYMENT:
Primarily desk work, involving both computer and paperwork, meetings both on and off-site.
Founded in 1861, the University of Washington is one of the oldest public institutions in the west coast and one of the preeminent research universities in the world. The University of Washington is a multi-campus university comprised of three different campuses: Seattle, Tacoma, and Bothell. The Seattle campus is made up of sixteen schools and colleges that serve students ranging from an undergra...duate level to a doctoral level. The university is home to world-class libraries, arts, music, drama, and sports, as well as the highest quality medical care in Washington State and a world-class academic medical center. The teaching and research of the University’s many professional schools provide undergraduate and graduate students the education necessary toward achieving an excellence that will serve the state, the region, and the nation. As part of a large and diverse community, the University of Washington serves more students than any other institution in the Northwest.