Job Description

At Elara Caring, we have a unique opportunity to play a huge role in the growth of an entire home care industry. Here, each employee has the chance to make a real difference by carrying out our mission every day. Join our elite team of healthcare professionals, providing the Right Care, at the Right Time, in the Right Place.

REMOTE POSITION!!!

MUST HAVE HOME HEALTH & HOSPICE EXPERIENCE

TheAppeals Analystperforms medical record reviews todeterminethe quality of care,identifiesquality issues,and assures compliance with medical record standards and regulatorymandatesasrelated to billing complianceThe incumbent analyzessubmittedclaims and/or claims to besubmittedas well as medical records todeterminebenefit coverage for medical services under review.This position educates providers on all aspects ofmedical record criteriatodeterminebenefit coverage for medical services. This position prepares written documents and/or reports of completed medical review determinations andsubmitsrecords to the payer, as requested.

JOB REQUIREMENTS:

• EDUCATION:Must be a graduate from anaccreditednursingschoolABachelor’s Degreein Nursingis preferred

• EXPERIENCE:Minimum three (3) years of experience as a registered nursein a home health and/or hospiceclinical care settingisrequired Prior functional working experience in medical records review arena (Utilization Review, Case Management and knowledge ofappropriate billingand coding guidelines) isrequired

• CERTIFICATION/LICENSURECurrentLicense as a Registered Nurseis required

• SKILLS

• Interpersonal skills and ability to manage workload and meet deadlines

• Demonstratedprofessional oral and written communication skills

• Demonstratedstrong organizational skills as well as autonomy with tasks assigned

• Demonstratedability to think critically and adapt to changes

• Excellent analytical,problem solving, andnegotiationskills

• Ability tocomprehendmedical policy and criteria to clearly articulate health information

• Demonstratedongoing understanding of current Medicare, Medicaid, and third-party regulations as changes occur

• Demonstratedknowledge in all levels of home health, hospice, palliative, and home medical equipment practices

• Demonstratedproficiencyin use ofMicrosoft Office Suite (Excel, Microsoft Word, Power Point, Outlook)

• TRANSPORTATION:Not applicable

• TRAVEL:Not applicable.

• HEALTH STATUS: Meets all applicable agency policies and procedures related to health screening and requiredtesting.

KEY ACCOUNTABILITIES

• Ensures that all activities performed align with the vision of Elara Caring’s board of directors, executive team, and the leadership of theComplianceteam

• Promotes compliance with all regulatory standards, through review of medical records.

• Maintains productivity, quality, and accuracy targets set by the Governmental Review Manager.

• Participates in Administrative Law Judgehearings as the company expert.

• • Educates providers on all aspects of medical review criteria.

  • Participates in the appeals process for claims denied by the government or other payers, as necessary.

  • Collectsappropriate medicalrecords, reviewsthe documentationfor validity, andsubmitsthe requested documents for pre-claim reviews, ADR requests, and/or appeals.

  • Collaborates with providersto adhere to clinical standards of careto ensure appropriateoutcome

  • Practices andadheres to departmental, state, and national guidelines.

  • Communicates with agencies related to documentation needsin a timely mannerandfollowsup with agency leadership, as needed.

  • Conducts audits, as needed to ensuredocumentationadequacy

  • Provides education related to audit trends and denials.

  • Communicates significant findings, problems, and changes related to compliance with documentation standards to the director and other personnel involved with patient care

  • Identifiesand communicates toGovernmental Review Managerand other supervisorypersonnelvisit documentation that lacks adequate content to support billing guidelines

  • Participates in the development of strategies/education to prevent loss of revenue during recovery audits

  • Assistswithdevelopmentof staff education tools/guides to promoteappropriate clinicaldocumentation and utilization

  • Writes business letters and reports to explain determinations and decisions to a variety of audiences, including, but not limited to governmental payers, private insurance providers, and administrative law judges

  • Participates in all levels of appeal, using regulatory guidance and critical thinking to navigate appeals compliantly.

  • Promotes, coordinates, and evaluates operational Systems to enhance operations and promote efficiencies.

  • Provides leadership to team and support staff inidentifyingagency/client needs and opportunities for improvement.

  • Promotes Elara Caring’s philosophy, missionstatementand administrative policies to ensure quality of care.

  • Maintains patient and staff privacy and confidentialitypursuant toHIPAAPrivacy Final Rule.

  • Performs other duties/projects as assigned

  PHYSICAL AND ENVIRONMENTAL DEMANDS:

  • Mentallydemanding, high stress environment

  • Sit, stand, bend, lift and move intermittently and be able to lift at least 25lbs.

  • Move equipment and supplies necessary for job functions

  • Read, speak, and write Englishin order tofulfill job functions in an understandable way

  • See/hear or use prosthetics that enable accomplishment of job

  • Meet the health requirements of the agency

  • Possible exposureto infectious and communicable diseases, chemicals, and repetitive motions

  • Abide by all occupational safety and bloodborne pathogen protocol to minimize illness and/or injury

  • Complete required workdaily

  • Cope with work involving ill, disabled, and dying patients

Equal Employment Opportunity We are proud to be an equal opportunity workplace and comply with state and federal affirmative action requirements. Individuals are recruited, hired, assigned and promoted without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, protected veteran status, or any other protected characteristic. If you require assistance due to a disability in the application or recruitment process, please submit a request via email at recruiting@elara.com.

Pay & Benefit Information Compensation for this role will be determined based on a variety of factors, including qualifications, skills, competencies, and relevant experience. Elara offers a broad range of benefits. Learn more at https://careers.elara.com/us/en/benefits

EVerify Elara Caring participates in E-Verify after a job offer is accepted and Form I-9 completed.