This position provides comprehensive assessment, coordination, implementation and reporting of complex clinical data. This position audits medical records on behalf of hospital clients for denials review, defense audits, disallowed charges and retrospective or concurrent reviews. The Clinical Nurse Reviewer assesses the patient’s plan of care and progress of the patient throughout an acute care admission. The intensity of assessment is situational and appropriate based on payer requirements. This position works independently receiving supervision of work activities from the Manager Case Manager. This position does not supervise other positions.

1. Analysis of Medical record
   • Completes analysis of records against established Milliman criteria, AHCCCS criteria, to determine if patient condition and or care meets specific criteria, including avoidable day studies, managed care or AHCCCS reconsideration/appeals and Medicare appeals.
   • Uses Milliman intensity and severity criteria/guidelines/paths to determine admission status, level of care, and continued provision of services as evidenced by audit.
   • Provides ongoing management of denials and appeals with the Patient Financial Services department. Reports all trends with Case Manager reviews and denial tracking to Manager, Case Management.
   • Performs prospective and retrospective reviews of medical records to identify and or defend charges to include but not limited to defense audits, stop-loss audits, patient inquiry audits, charge-hold audits and biller-requested audits. Creates denial and appeal for medical necessity case that have been denied.
   • Reviews and participates in State Fair Hearings for denials and appeals.
   • This position performs onsite job duties and responsibilities at Phoenix Children’s Hospital, and is viewed as an accessible member of the healthcare team.
   • Applies critical thinking to denial analysis and management.
2. Develops Collaborative Healthcare Team
   • Collaborates with health care team partners on level of care, identified barriers, and other issues that may impact reimbursement.
   • Establishes a collaborative relationship with physicians, medical directors, nurses and other unit staff, Revenue Cycle management and staff, and payers. Mentors internal members of the health care team on utilization management and managed care concepts.
   • Identifies from review of documentation opportunities for increased education with physicians and the healthcare team.
   • This position performs onsite job duties and responsibilities at Phoenix Children’s Hospital, and is viewed as an accessible member of the healthcare team.
   • Participates in weekly department process improvement meetings.
3. Regulatory Documentation
   • Participates in various aspects of the revenue-cycle by documenting in AMPFM, SCM, and MIDAS avoidable days, extended length of stay, authorizations, and denials for medical necessity.
   • Performs clinical auditory management in accordance with all state mandate regulations,
   • understands and focuses on key performance indicators, and promptly reports
   • potential denials to health care team.
   • Performs utilization management in accordance with all state mandate regulations,
   • understands and focuses on key performance indicators, and promptly reports
   • potential denials to health care team.
   • Collects data and other information required by payers to fulfill utilization and regulatory requirements.
4. Utilization Management
   • Attends insurance meetings with Utilization Medical Director and Manager, Case
   • Management as needed. Attends Denial Committee meetings with Hospital Revenue
   • Cycle/Physician Revenue Cycle staff as needed.
   • Communicates with Utilization Medical Director all denials requiring a physician to
   • physician conversation.
   • Obtains and reviews medical necessity denial reports. Analysis and documentation for monthly UMRC report. Reports to Hospital Revenue Cycle denial committee findings of report.
5. Financial Accountability
   • Participates in various aspects of the revenue-cycle by documenting in AMPFM, SCM,
   • and MIDAS avoidable days, extended length of stay, authorizations, and denials for
   • medical necessity. Completes monthly documentation and financial audits as requested by department manager and director.
   • Provides ongoing management of denials and appeals with the Patient Financial
   • Services department. Reports all trends with Case Manager reviews and denial
   • tracking to Manager, Case Management and Director Case Management & Social Service.
   • Responsible for all facets of inpatient denials due to lack of clinical medical necessity
   • for the Case Management department. Communicates and documents all potential
   • denials and non-certified days.
   • Working knowledge of DRG payment system and impact of ICD-10 on physician documentation.
6. Provides Excellent Customer Service
   • Establishes a collaborative relationship with physicians, medical directors, nurses and
   • other unit staff, Revenue Cycle management and staff, and payers.
   • Provides cross coverage to all clinical nurse review responsibilities.
   • Provides excellent service routinely in interactions with all customers, i.e. coworkers, patients, visitors, physicians, volunteers, etc.
   • Responds to emails within 24 hours.
   • Clear communication skills with all internal and external customers.
7. Performs miscellaneous job related duties as requested.

Mission

To advance hope, healing and the best healthcare for children and their families

Vision

Phoenix Children's will be the leading pediatric health system in the Southwest, nationally recognized for exceptional care, innovative research and advanced medical education.

We realize this vision by:

• Offering the most comprehensive care across ages, communities and specialties
• Investing in innovative research, including emerging treatments, tools and technologies
• Advancing education and training to shape the next generation of clinical leaders
• Advocating for the health and well-being of children and families

Values

• We place children and families at the center of all we do
• We deliver exceptional care, every day and in every way
• We collaborate with colleagues, partners and communities to amplify our impact
• We set the standards of pediatric healthcare today, and innovate for the future
• We are accountable for making the highest quality care accessible and affordable