Rehab Authorization and Appeals Specialist

Primary Purpose 

Increases rehab admissions through screening potential rehabilitation clients and facilitating authorization and appeals. Assists with coordinating legal support and hearings. Provides education and advocacy for patient access to rehabilitation services. 

Major Responsibilities 

• Understands and maintains knowledge of Inpatient Rehabilitation Facilities (IRF) Medicare Criteria and necessary functional and medical complexity that would qualify a given patient for IRF
• Identifies patients who would benefit from IPR and makes appropriate post-acute DC recommendations
• Utilizes excellent knowledge of appropriate medical and rehab documentation and makes recommendations to internal stakeholders to improve documentation that supports IRF admission as appropriate
• Serves as an expert in managing denials and appeals for IRF authorization process
• Diligently communicates with payors by phone, fax, or email to follow up on authorizations and appeals within the expedited timeframe
• Manages accurate data gathering and reporting for No Delay Program for Inpatient Rehabilitation (IPR) and rehab authorizations and appeals in cooperation with Data Analysts
• Collaborates with teammates involved in data analysis for reporting outcomes
• Serves as a resource for teammates regarding EPIC Rehab Auth Workflow
• Articulates reasoning for No Delay Authorization in a way that is understandable by multiple audiences and for people of different backgrounds including patients, families, and teammates
• Communicates with patients and their families about their specific appeal situation and provides follow up
• Obtains a properly executed Appointment of Representative (AOR) form as needed and follows HIM guidance for scanning to the medical record
• Provides timely updates to all necessary teams and documents appropriately in medical record when expedited appeals are upheld and case will be considered for Administrative Law Judge (ALJ) hearing review
• Serves as a contact person for ALJ offices and communicates with legal assistants regarding matters related to hearings and case files
• Demonstrates a high degree of comfort and confidence working with a team of physicians and lawyers
• Is prepared to speak in hearings to a judge and legal teams
• Identifies and communicates areas for continuous improvement within the defined process of No Delay Authorizations 
• Demonstrates comfort in navigating, understanding, and communicating information within the electronic health record
• Completes other duties as assigned

Minimum Job Requirements 

Education:  Bachelor’s Degree required. Trained and qualified clinician: RN, PT, OT, SLP, N or PA.

Certification / Registration / License:  Current license in respective clinical field required. 

Work Experience: 3-5 years experience in acute care hospital and/or inpatient rehabilitation setting.

Knowledge / Skills / Abilities

Must have a valid driver's license and a vehicle to conduct such travel. Communication skills, organization skills, attention to detail, ability to problem solve, and analyze data.  Knowledge of Microsoft applications including Excel, PowerPoint, and Word. 

Physical Requirements and Working Conditions

Requires frequent car travel, walking, standing, sitting, some lifting, reaching, bending, stooping, pushing and pulling. Must lift some articles up to twenty-five pounds. Can move about to accomplish tasks. Ability to clearly and concisely express and exchange ideas via spoken and written English word, conveying detailed information to others accurately and, on occasion, quickly. Must have excellent presentation skills and service excellence. Travel by car required with frequent day trips and occasional overnight travel about once per month