Job Abstract

AIC is a leading provider of Immunoglobulin Replacement Therapy, Alpha-1 Augmentation and Infusion Care. With our diverse culture, and our values around Innovation, Stewardship, and Unity, we are committed to Advancing Quality, and Improving Lives. We are dedicated to doing more for our patients by providing quality products and services that enhance the entire care experience.

Advanced Infusion Care is our home infusion division specializing in intravenous (IV) and subcutaneous (Sub Q) immunoglobulin therapy patient care.  We are looking for an experienced and motivated Clinical Review Specialist to join our dynamic team!  This role is a full-time position responsible for Clinical Review, Insurance Clinical Criteria Review, Denial and Appeal Response, and securing charts for clinical criteria requirements.

The perfect candidate should have outstanding communication skills, an in-depth knowledge of diagnostic requirements and insurance criteria practices.  The ideal candidate should also understand diagnostic work ups, laboratory results, insurance critieria requirement, denial management and appeal process.  CPR + experience is a Plus.

We offer great benefits, including health, vision and dental insurance, long term disability insurance, life insurance, a vacation package, 401K plan with a generous employer match, hybrid office/ Remote work from home opportunity, growth, and more

JOB SUMMARY:

This position is responsible for providing a complex medical review for chronic patient care, assessing the chart documents and the medical policy for insurance providers and effectively communicating the requirements, met or not met, to internal and external customers to facilitate effective onboarding of patients. This position is also responsible for working with all departments and referral sources to facilitate clean claims activity for both initial and reauthorization of assigned therapies.

REQUIRED EDUCATION AND EXPERIENCE:

• Graduate of an accredited school of nursing.
• Licensed LPN/RN, in good standing with the practicing state’s Board of Nursing.
• Minimum three (3) years of nursing experience required with home health experience preferred.
• Home Infusion experience preferred.
• IV certification (CRNI) or other infusion-related certification preferred.
• Current CPR certification.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Recognize patients’ rights and responsibilities and support them in the performance of job duties; respect patient’s rights to privacy and confidentiality.
• Provide a clinical review of all new specialty (and other therapies assigned) referrals to determine if the payers criteria has been met.
• Provide guidance and support to the Financial Services and Intake Teams (and others assigned) to improve the initial and reauthorization process.
• Provide guidance and support to staff as it relates to improving their understanding of how the time frame between referral and authorization can decrease.
• Documentation and communication of each evaluation will be verbal, email, and in the EMR.
• Manage, improve, and define the core relationship between the field team (pharmacy, intake, financial services, nursing and sales) in the specialty admissions/intake process.
• Identify and plan opportunities to increase IG volume and capture rate.
• Participate in strategic planning to identify opportunities to improve service and reduce cost in the IG admission/intake process.
• Build a strong, direct relationship with team members that facilitate open communication and provide sound clinical support during onboarding and reauthorization process for assigned patients by therapy.
• Coordinate the authorization process with the financial services team to facilitate obtaining authorization based on payer criteria, and Formulary, in the shortest amount of time that minimizes referral source interruption.
• Work directly with appropriate team in maintaining clinical responsibility following company’s nursing and pharmacy policy, as well as Nurse Leadership direction.
• Communicate with the Nurse Manager, Intake, Financial Services, Sales and Pharmacists on supporting documentation needed to qualify a patient for their benefits and alert teams when authorization can be applied for with the highest opportunity to successfully obtain authorization.
• Work with Intake to assist in correcting any deficiencies and/or trends noted.
• Communicate in a professional manner under the guidelines of regulatory, licensing and accrediting agencies, and the policies and procedures of the company.
• Keep abreast of State and Federal laws, licensure, and accrediting bodies guidelines which apply to home infusion services and ambulatory infusion suites.
• Participate in the development of and adherence to all organization’s policies, procedures and protocols.
• Facilitate educational programs for external customers and/or referral sources.
• Ensure the completion of the appropriate documentation to facilitate reimbursement. This includes, but is not limited to, reviewing the plan of treatment, physician’s orders, Statement of Medical Necessity, certification and any additional documentation required.
• Ensure current and accurate communications with the patient’s physician, pharmacy (if applicable) and any additional health care provider.
• Ensure that the safety of the patient and staff is always the first priority.
• Participate in the Performance Improvement Plan.
• Adhere to the performance programs, policies, procedures, guidelines, and internal control standards established by AIS HealthCare.
• Understand proper internal control procedures associated with the specific job function as communicated by his/her manager.
• Take responsibility for reporting concerns that he/she may have with respect to deficiencies in internal control.
• Share knowledge gained with other staff members and works as a team.
• Interact with others in a positive, respectful, and considerate manner.
• Perform other job-related duties as assigned.

QUALIFICATION REQUIREMENTS:

• Excellent interpersonal communication and organizational skills.
• Strong in cross-functional communication and collaboration.
• Strong work ethic with personal qualities of integrity and credibility.
• Knowledge or ability to quickly learn commonly used concepts, practices and procedures within the nursing filed.
• Ability to communicate effectively and professionally with patients, visitors, physicians, and coworkers.
• Expresses ideas clearly, both in written and verbal communications and provides strong documentation.
• Ability to work in a team environment, while also delivering independent results.
• Demonstrate extreme attention to detail and accuracy.
• Resourceful, flexible, and well organized.
• Knowledge of accreditation standards, laws and regulations and industry standards of practice.
• Knowledge of professional nursing theory and scope of practice to assess patient needs and administer and evaluate patient supportive care.
• Ability to train employees/colleagues.
• Support and promote departmental goals and initiatives.
• Advance computer proficiency.
• Knowledge in the use of Microsoft applications.

Steps to Apply:

·         Complete the required Culture Index Candidate Assessment (Directions to follow below in this job posting, so please read in its entirety). *** No application will be considered if the applicant does not follow instructions and complete the assessment as part of the application process.

Culture Index Candidate Assessment

Why does AIS utilize the Culture Index Assessment?

We recognize how important our employees are to the success of our company. Our company continues to thrive due to a culture of teamwork and our ability to match potential hires with positions that best utilize their natural traits and skillsets. AIS utilizes the Culture Index Candidate Assessment surveys to help us select the best match for our positions.

How can I complete the assessment?

Copy and paste the following link into your browser and press enter. Then, select the corresponding position for which you are applying. (Only one assessment per candidate is required.) The assessment is brief, taking less than ten minutes to complete.

portal.cultureindex.com/public/survey/general/0BFB8F0000

AIS HealthCare™ is the leading provider of advanced sterile, patient-specific intrathecal pump medications and in-home intravenous infusion, including immune globulin therapies. These services, combines with your advanced nursing and care coordination solutions, assist physicians and hospitals in delivering a superior level of care for optimal therapeutic outcomes.

We offer a wonderful work culture, looking for an impact player who is positive, earnest and hardworking. For more information on our company, please visit our website at www.aiscaregroup.com.