Director Revenue Cycle / Prior Authorization (RN)

Why Yuma Regional Medical Center? Yuma Regional Medical Center (YRMC) is located in Yuma, AZ. Our purpose is building a healthier tomorrow. We strive by putting patients first as they are the center of every decision and action we take. YRMC is rooted in the community by living and breathing the dynamic nature of our region. Being committed to progress by constantly and consistently advancing healthcare, creating meaningful experiences and improving the lives of everyone around us. Our Values Bring Kindness | Achieve Together | Aspire For Better | Do The Right Thing | Lead With Optimism | About Yuma, AZ Named by the Guinness World Records as the Sunniest City on Earth with winters averaging temperatures of 70 degrees, sunny days and cooler nights. Yuma, Arizona is a place to explore the great outdoors with hiking, jet skiing, boating and off-roading. Don’t forget to soak up the sun at the great Colorado River or one of Yuma’s many lakes. Yuma is centrally located in Southwest Arizona, within a short drive to many popular attractions and destinations. https://www.visityuma.com/ https://www.yumachamber.org/ Bring your skills to one of the sunniest places on earth - Yuma, AZ!

Work Status Details: REGULAR FULL TIME | 80.00 Hours Every Two Weeks Shift: Days Pay Rate Type: Annual Salary Location: Remote Listed is the base hiring salary range offered for this position. Actual salaries may vary depending on factors, including but not limited to skills and experience. The salary range listed is just one component of the total rewards/compensation package offered to candidates. Min = $110,545.35 Mid = $143,709.03 Max = $176,872.55 Summary: The prior authorization nurse reviews requests for medical treatments, services, or procedures to determine whether they qualify for insurance coverage. The job requires the nurse to assess, evaluate, and provide recommendations to help ensure patients receive the services they need; he/she will evaluate authorization requests and authorize, modify, or pend per appropriate criteria. They will also refer authorization requests not meeting criteria to specialty physician reviewer according to established medical necessity, benefit, and eligibility criteria to assure appropriate, efficient, and timely medical care. Collaborate with payers regarding appeals process for services rendered. Director will have oversight and planning for HIM management for inpatient, outpatient, and physician services records and coding; Monitors HIM goals intradepartmental and Revenue Cycle; Implements processes and strategies for the HIM department including scanning, Release of Information, duplicate medical records, transcription, and coding; Collaborates with hospital departments and ambulatory clinics, interacting with internal and external customers, to build relationships and achieve results;

Review and process urgent and non-urgent authorization requests (via phone, fax, and electronic submission) for medical necessity (according to established criteria) and authorize, pend, or modify as appropriate Obtain additional medical information as necessary from requesting provider. Communicate with providers and members regarding status of authorization requests Collaborate with centralized Authorization specialist to ensure bi-furcation process of information submitted to payers Review and Research Authorization denials in collaboration with PFS and other teams, as necessary. Review and submit appeals for denied services. Assist with submitting appeals that are in via pending in WQ’s Collaborate with Medical Directors and other designated physician leaders for making clinical decisions. Review and process urgent and non-urgent authorization requests (via phone, fax, and electronic submission) for medical necessity (according to established criteria) and authorize, pend, or modify as appropriate. Utilize a variety of medical necessity, contractual and benefit criteria to determine appropriate authorization decisions. Obtain additional medical information as necessary from the requesting provider. Assist interdepartmental staff members to resolve issues relating to the authorization process. Refer information regarding members to other departments as appropriate for follow-up (i.e., Case Management Process authorization requests (routine, urgent and retrospective) according to department performance standards. Collaborate with Medical Directors and other designated physician leaders for making clinical decisions. Perform other duties as assigned by supervisor/manager. Develop and maintain controls within Health Information Management (HIM); Directs and develops high functioning operations and coding teams that includes manager, supervisor and team lead levels that support delegation and oversight. Continually assess and develop an organizational structure that supports high performance results Monitors and reports on key metrics including, but not limited to: Coding AR days in HB and PB, Release of Information turnaround, transcription turnaround, and coding accuracy Completes monthly trending analyses and presents findings at monthly operational review meetings to senior revenue cycle leadership. Maintains deep understanding of key processes within the department and constantly evaluates opportunities for improvement; Ensures standardization of processes. Collaborates with legal and compliance departments on matters that affect hospital billing. Provides guidance for operations and coding to resolve internal and external issues; Routinely conducts accuracy analysis, to ensure optimal reimbursement. Other duties as assigned.