Saint Francis Health System

Authorization Specialist

• Ensure accuracy of insurance information and obtain prior authorization and predetermination requirements for non-oncology infusions, oncology infusions, and radiation oncology
• Monitor patient, referral, and denial work queues to identify encounters requiring pre-registration, verification, authorization, or corrections
• Process encounters according to assignment and meet daily and weekly productivity goals
• Evaluate physician orders and pre-screen for medical necessity
• Review treatment plan frequency and duration and communicate with ordering providers or clinical staff regarding order revisions
• Review clinical documentation for CPT and diagnosis codes supporting authorization and precertification according to payer guidelines
• Monitor, review, and process authorizations for accuracy, timeliness, and insurance-guideline compliance
• Consult with pharmacy team members regarding provider-ordered drugs, payer preferences, authorization codes, and treatment-regimen appropriateness under NCCN and payer guidelines
• Coordinate with patients, referring physician offices, referring locations, scheduled service areas, financial counselors, case managers, and others to obtain or provide information
• Document pertinent information and efforts in the computer system according to department standards
• Protect the privacy and security of patient health information
• Work directly with patients, customers, healthcare professionals, and staff by telephone or face-to-face interaction

Authorization Specialist – II

Nurse

• Assess, plan, implement, and evaluate nursing care using the nursing process and hospital standards
• Monitor and evaluate patient functional status in a virtual environment
• Perform admissions, discharges, chart reviews, and other patient care duties through a secure link to patient rooms
• Document nursing-process steps using proper medical terminology
• Facilitate patient discharge through timely referrals and patient education
• Collaborate with other disciplines and healthcare professionals
• Support unit and hospital goals through performance-improvement and educational activities
• Prevent patient problems through telemedicine observation, surveillance of adverse physiological trends, prophylactic strategies, and chart review
• Virtually evaluate patients and educate patients and families on disease processes and procedures
• Perform clinician, educator, consultant/collaborator, and navigator responsibilities during virtual appointments
• Coach and mentor floor nurses regarding patient care
• Maintain knowledge of changing patient-care technology and equipment
• Coordinate activities and lead others in the same work without supervisory responsibility

Registered Nurse II – Virtual Nursing

• Assess, plan, implement, and evaluate nursing care in a virtual environment
• Perform admissions, discharges, chart reviews, and other patient care duties via a secure link to patient rooms
• Monitor and evaluate patient functional status and patient care outcomes
• Document the nursing process and use proper medical terminology
• Facilitate patient discharge through referrals and patient education
• Collaborate with other disciplines and healthcare professionals
• Support unit and hospital goals through performance improvement and educational activities
• Prevent patient problems through telemedicine observation, surveillance of adverse physiological trends, prophylactic strategies, and medical chart review
• Virtually evaluate patients and educate patients and families on disease processes and procedures
• Perform clinician, educator, consultant/collaborator, and navigator responsibilities during virtual appointments
• Coach and mentor floor nurses regarding patient care
• Maintain knowledge of changing technology and equipment used in patient care
• Coordinate activities and lead others in the same work without supervising

Registered Nurse I – Virtual Nursing

• Monitor patient, referral, and denial work queues to identify encounters requiring pre-registration, verification, authorization, or corrections
• Work encounters according to assignment while meeting daily and weekly productivity goals
• Evaluate physician referral and authorization requirements and ensure requirements are met before procedures
• Review clinical documentation for CPT and diagnosis code information supporting authorization/precertification
• Monitor, review, and process authorizations in accordance with timelines and insurance guidelines
• Coordinate with departments and ancillary areas for special needs or resources
• Counsel clinical partners and patients to obtain additional payer-required information
• Coordinate with patients, referring physician offices, referring locations, scheduled service areas, financial counselors, case managers, and others
• Document pertinent information and efforts in the computer system
• Protect the privacy and security of patient health information
• Work independently and make minor decisions in a complex technical or professional field
• Work with patients, customers, healthcare professionals, and staff by telephone or face-to-face

Credentialing Coordinator

• Obtain and verify all required credentialing and recredentialing documentation
• Work with staff and hospital system leadership to ensure applicants have proper credentials and training to provide patient care
• Perform duties according to Medical Staff policies, bylaws, rules, regulations, and applicable legal, state, federal, licensing board, Joint Commission, and Risk Management guidelines
• Assist the Credentials Chairman and Supervisor of Medical Staff Services with privilege documents, credentialing policies, rules, and regulations
• Coordinate appointment, reappointment, and credentialing processes for medical staff and allied health professionals
• Ensure accurate documentation and verification of education, experience, and licensure
• Ensure compliance with Joint Commission standards, Medical Staff bylaws and credentialing policies, and National Practitioner Data Bank guidelines
• Initiate background checks and verify education, experience, and licensure using online systems, correspondence, telephone inquiries, and reference questionnaires and reports
• Design and implement systems for compiling, maintaining, and retrieving complete confidential medical staff records
• Monitor environmental changes for new requirements or collaboration opportunities and communicate them appropriately
• Support Medical Executive Committee and Credentials Committee meetings, including meeting minutes, follow-up actions, and monthly credentialing updates
• Serve as a resource for internal departments on credentialing issues, clinician privileges, and health plan participation changes
• Maintain accurate provider information databases
• Coordinate activities of others without supervisory responsibility
• Work with patients, customers, healthcare professionals, staff, and Director-level personnel

Auditor

• Ensure coding specialists are well-trained and up-to-date on regulatory requirements affecting coding compliance and hospital reimbursement
• Ensure coding data quality, accuracy, and timely submission to state, federal, and hospital data repositories
• Maintain current knowledge of coding rules and guidelines
• Serve as liaison with Patient Access and Patient Billing Services
• Continuously monitor the quality of coded data
• Perform monthly focused audits on all coders and maintain a 95% accuracy rate
• Randomly audit a percentage of each coder's work monthly for accuracy and compliance
• Audit focus DRGs based on outcomes to ensure regulatory compliance
• Ensure timely submission of coded accounts affecting hospital reimbursement
• Research outstanding accounts and ensure completion
• Assign and monitor Educode modules
• Train and orient new coders
• Assist with physician queries for documentation
• Review monthly POA reports and produce individual and cumulative monthly quality reports
• Educate coders on LCDs, clinical coding guidelines, and other regulatory guidelines
• Coordinate activities and lead others without supervision

Authorization Specialist – II

Registered Nurse II – Virtual Nursing

Registered Nurse I – Virtual Nursing

Authorization Specialist

Credentialing Coordinator

Health Information Auditor