UCSD Layoff from Career Appointment or Special Selection: Apply by 01/20/2016 for consideration with preference for rehire. All layoff applicants should contact their Employment Advisor. Eligible ACCES or Special Selection clients should contact their Vocational Rehabilitation Counselor for Special Selection.
Under the direct supervision of the Chief Administrative Officer of Care Management and indirectly to the Chief Compliance and Privacy Officer, the incumbent will be responsible for the day to day management of clinical and professional medical necessity reviews using UCSDH policies and procedures, payor guidelines and regulatory guidelines within the Compliance Department and on behalf of UCSD Health, the UCSD School of Medicine, the Skaggs School of Pharmacy and the UCSD Medical Group.
Independently analyze and communicate Federal and State regulations related to inpatient and outpatient hospital clinical documentation requirements. Analyze and evaluate the accuracy of the clinical documentation process and conduct strategic risk assessment in order to ensure compliance. Participate in the development and implementation of policies, procedures and other monitoring tools in order to facilitate accurate claim submission. Serve as a subject expert to Patient Financial Services on complex clinical documentation situations and provide guidance on compliance related matters such as laws, regulations and programs.
Perform data analysis and develop reporting tools. Advise on issues relating to regulatory matters. Work cross functionally with the continuous documentation improvement team, revenue cycle and health information to proactively identify risks and respond to identified issues. Assist with coordination of responses to and resolutions of external investigations and audits. Develop presentations, audit summaries and process improvement plans. Perform other related duties as assigned.
Graduation from an accredited school of health information management and four (4) years of relevant experience; or a combination of experience and education.
Knowledge in medical terminology, anatomy and physiology.
Three (3) years of experience working in a hospital, medical group, or health plan environment managing clinical review for medical necessity and document integrity; and/or two (2) years in case management experience, clinical documentation improvement, clinical denials management, clinical review.
Experience with LCDs, NCDs, PEPPER, CERT, QIOs.
Knowledge of CMS and other payer documentation, compliance, reimbursement and coding requirements.
Knowledge of federal, state, and local billing and research compliance regulations.
Ability to assess clinical systems, such as identifying gaps between services required and services available.
Experience with program evaluation through outcomes measurement, including principles of continuous quality/performance improvement, use of benchmarks and analysis of trends, and other means to create understanding of current condition and return on investment.
Proficiency in Information Systems, databases, and in the use of technology and computer programs including MS Office (Word, Excel, Power Point, Outlook, etc.).
Ability to construct grammatically correct correspondence and reports using standard medical terminology.
Proven analytical and problem solving skills, ability to problem solve, engage in abstract thought, and successfully manage conflicts. Strong negotiation, organizational, delegation and task prioritization skills.
Strong communication skills (both verbally and in writing) and proven ability to effectively interact and maintain working relationships with operational, clinical, and financial stakeholders internal and external to the organization.
Ability to work effectively in a constantly changing environment and maintain a work pace appropriate to the workload, handling multiple tasks and meeting deadlines.
Ability to maintain a high level of confidentiality.
RN Credential - Bachelor of Science in Nursing (BSN).
Knowledge and ability to conduct medical necessity validation reviews.
Knowledge of DRGs and ICD-9, HCPCS and APC codes.
Knowledge of University policies and procedures.
Proficient with UCSD Health's computer systems including EPIC E.H.R and other information systems.
Knowledge of adult learning, instructional design, and curriculum development techniques including use of multimedia / E-L
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