This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Do you have clinical care experience? Are you an RN looking to grow your career? UPMC is hiring a full-time Authorization Nurse. This position works Monday through Friday, as well as rotating weekends (typically 1 every 5-6 weeks) and holidays (usually 1 per year), during daylight hours. Additionally, this position is eligible to work from home. The Authorization Nurse provides support to appropriate UPMC departments and healthcare providers by obtaining referrals and/or authorizations for any acute admissions, hospital services, and treatments. The employee uses their knowledge of acute care experience and payer regulations to assess medical necessity and ensure the presence of supporting documentation to obtain authorization. Additionally, they communicate pertinent clinical information to Physicians, Medical Directors, or CFO. - Serve as a liaison between care managers and payors and facilitates payor/physician contact when indicated. - Communicate to the Medical Directors, Attending Physicians and/or CFO, if indicated, regarding evaluation of medical appropriateness. - Act as a resource to other departments as well as the care managers leveraging clinical expertise relative to the authorization process. - Collaborate with other departments to ensure all information/documentation is obtained to support authorization, level of care and/or medical appropriateness. - Ensure clinical review process is followed in order to meet payor deadlines. - Report to management on an ongoing basis trends/barriers that could necessitate process improvement from a concurrent standpoint. - Assist in determining system-wide care management needs through investigation of authorization process and identification of root cause. - Identify and assign a root cause to each case to ensure denial reasons are tracked. - Monitor and evaluate for area of process improvement related to the payor specific authorization process. - Maintain current knowledge of regulatory guidelines related to authorizations. - Perform clinical review for cases referred for cases requiring authorization or adherence to payor medical policies. - Maintain collaborative relationships with utilization management and departments at payor organizations. - Provide ongoing education/feedback to care managers and other departments as related to the payor specific authorization process. Qualifications - RN required; BSN or Bachelor's degree preferred. - Licensed in practicing state. - 5 years of acute care clinical experience. - 2 years payer or care management experience. - Understanding of clinical and care management process. - Knowledge of medical necessity criteria (InterQual). - Ability to apply InterQual criteria appropriately. - Prior utilization review experience. - Knowledge of payer reimbursement structure. - Excellent customer service skills. - Negotiation skills for obtaining appropriate level of care. - Critical thinking/assessment skills. - Self-motivation/autonomy. - Organization/time management and prioritization skills. - Proficient in Microsoft Word and Microsoft Excel. - Experience working with databases preferred. Licensure, Certifications, and Clearances - Registered Nurse (RN) - Act 34 - Current licensure either in the state where the facility is located or, if the facility is in a state covered by the multistate Nursing Licensure Compact (NLC) agreement, a multistate license issued by a participating NLC state. - Hires and current employees working on an out-of-state NLC license who later change their residency to the state where the facility is also located will have 60 days upon changing their residency to apply for licensure within that state.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Physician Services Care Advocate is a professional who provides services to patients and those supporting them who are navigating the complex healthcare continuum. The advocate works directly with patients (or with their legal representatives) to ensure they have a voice in their care and information to promote informed decision making. The Physician Services Care Advocate serves as an educator to internal and external key stakeholders. - Promotes the philosophy, mission statement and administrative policies of Optimal Care Physician Services to ensure quality and consistency of patient care - Fosters positive morale among staff, by promoting open communication with all departments, to help create and maintain an innovative and cooperative staff relationship and environment - Participates in quality improvement activities - Attends and participates at Optimal Care Physician Services organized functions which relate to community and public awareness - Receives, interprets and manages patient needs with the intent of assessing for appropriate services - Maintains daily communication with Departments and Team and direct reports - Maintains visibility and accountability to increase relationships within the company - Acts as a liaison with direct-care clinical teams on behalf of providers and patients/families - Acts as liaison with clinical supervisors, physicians, and team members on behalf of patients and families - Provides consultation on appropriate care services and/or specialty programs Qualifications - Associate degree: preferably as a licensed RN or LPN, vocational nurse, or in the social work/psychology field - A licensed or unlicensed individual who is otherwise qualified by education, training, or has experience in the performance of selected acts, tasks, or functions - Minimum two years experience in home health, hospice, or critical care navigation - Knowledge of clinical manifestations of diseases and ability to develop specific clinical knowledge - Understanding of specialty programs, and available services for eligible patients - Excellent communication, negotiation and public relations skills - Excellent presentation and public speaking skills - Compliance with accepted professional standards and practices - Reliable transportation and valid automobile insurance coverage Desired Qualifications - General nursing, Social Work, or Care Management knowledge preferred Location - Office Location: Jackson, MI - This is a remote position for those living in MI, OH, or IN only Hours - 8:00 am – 5:00 pm, Monday through Friday Pay Range - $20 — $26 USD Background Screening Optimal Care conducts a background screening upon acceptance of a contingent job offer. Background screening is completed by a third-party administrator, the Michigan Long-Term Care Partnership, and is performed in compliance with the Fair Credit Report Act. Reasonable Accommodations We will ensure that individuals with disabilities are provided reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. Please contact us to request accommodation. Equal Opportunity Employer Optimal Care is an equal-opportunity employer. Benefits - Minimum of 3 Weeks Paid Time Off (PTO) - Company Vehicle Program - Mentorship Culture - Medical, Dental, and Vision Insurance - 401(k) with Employer Match - Mileage Reimbursement - Cutting Edge Technology

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description This position is responsible for abstracting provider services accurately into billable codes from the medical documentation in accordance to the coding ethics of American Academy of Professional Coders (AAPC), American Health Information Management Association (AHIMA) and/or National Alliance of Medical Auditing Specialists (NAMAS) and payer coverage guidelines. - Responsible for abstracting provider services into billable codes (CPT, HCPCS, & ICD-10) from the medical documentation in accordance with the coding ethics of AAPC, AHIMA, and NAMAS and payer coverage guidelines in an accurate and timely manner. - Post and reconcile hospital setting (IP/OP/OBS) charges daily. - Communicate inefficiencies to the coding supervisor such as the medical necessity of services; unspecified truncated and lack of supporting diagnoses; incomplete or missing documentation along with any inappropriate coding and documentation trends. - Reference coding and payer resources to accurately code and bill the provider documented services. - Assist the AR Specialist with complicated coding denials and create appeal letters regarding the coding denial along with any supporting documentation. - Continue education with coding and billing via Encoder Pro, coding subscriptions and resources provided by CHP. - Other duties as assigned. Qualifications - Have experience properly coding (CPT, HCPCS, & ICD-10) services from the medical documentation in accordance with the coding ethics of AAPC, AHIMA, and NAMAS. - Must be able to communicate effectively in English, verbally, and written. Additional languages are desirable. - Excellent customer service and phone etiquette skills. - Must be able to maintain a high degree of confidentiality and work well under productivity standards. - Able to prioritize and balance the workload on short and long-term company needs. - Must be able to work independently and be able to solve problems efficiently and accurately. - Able to create channels of communication to obtain information necessary to perform job tasks. - Strong organizational skills with the ability to prioritize a high-volume workload. - Helpful attitude, positive teamwork spirit with a willingness to help. Requirements - High School Diploma or Equivalent required. - Minimum of 2 years of experience in medical billing and/or coding. - Certifications in Medical Billing and Coding highly desirable.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Redetermination (Appeals) Specialist supports the Medicare Appeals team by performing non-medical reviews, preparing redetermination letters, and ensuring timely and accurate processing. This role requires strong organizational skills, attention to detail, and the ability to work with reports, documentation, and multiple software tools in a fast-paced environment. - Perform non-medical reviews and process redetermination letters, ensuring accuracy and compliance with established timelines (50%) - Prepare unit reports, analyze and interpret workload data, and address processing issues using various software tools (30%) - Update letters, templates, and departmental documents as needed (10%) - Gather and prepare documentation for legal inquiries and administrative requests (10%) Qualifications - High School Diploma or equivalent required - Associate’s or Bachelor’s degree preferred - Minimum of 2 years of relevant experience in healthcare, insurance, or Medicare/Medicaid services - Customer service experience preferred - Medicare-specific experience preferred but not required; comprehensive training provided Requirements - Proficiency with Microsoft Office (Word, Excel, Outlook) - Strong organizational skills with excellent attention to detail - Effective written and verbal communication skills - Demonstrated ability to exercise sound judgment and handle confidential information - Strong spelling, grammar, and punctuation skills Benefits - 401(k) & matching - Dental insurance - Vision insurance - Health insurance - Life insurance - Paid Time Off (PTO) - Paid Holidays