Denial/Appeal Management Nurse (NE)

Job Description

DescriptionWhat You Will Do

• Collaborates and coordinates with all members of the health care team, patient and family (or significant others) to coordinate and ensure timely and efficient delivery of required workflow, services and tasks to result in:
  • Support of positive patient health care outcomes
  • Increased patient/health care team outcomes and satisfaction
  • Improved inpatient throughput and appropriate length of stay
  • Improved communication, awareness and adherence to regulatory requirements associated with utilization
  • Support for inappropriate level of care and decreased inpatient bed day denials
  • Continuity and coordination of care
  • Appropriate and timely authorization for level of care
  • Decreased denials
  • Appropriate reimbursement
• Perform timely and accurate review, denial communications and construct appeals, including remaining current with regulatory / payer and internal requirement.
• Collaborate with physicians, UM Nurses, PAS, and other members of the Interdisciplinary team and Revenue Cycle to collect all pertinent information to support successful appeals including communication of trends and appropriate escalation to ensure appropriate resolution resulting in expected payment.
• Document appeal activity according to department standards to support accurate and timely reporting of denial and appeal status, outstanding revenue and to help identify trends (payer, physician, service, DRG, reviewer). 20%
• Collaborate with supervisor to support training, and reinforcement resulting in decreased denials. 20%
• Conduct all UM activities with a focus on continuous quality improvement in a manner that is supportive of UHC quality initiatives and in compliance with applicable regulatory requirements

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

QualificationsEducation

• Graduate of an accredited school of Nursing (Required) and
• (BSN) Bachelor's Degree in Nursing (Preferred)

Work Experience

• 3+ years Clinical experience in acute care setting (Required) and
• 3+ years Of experience in managed care or utilization review (Preferred) and
• Experience and training on Interqual or MCG criteria (Required)

Knowledge, Skills, & Abilities

• Must have sound clinical knowledge base of the population to be served. (Required proficiency)
• Knowledge of Medicare, Medicaid and commercial payer regulations (Preferred proficiency)
• Detail-oriented and organized, with good analytical and problem solving ability. (Required proficiency)
• Notable client service, communication, presentation and relationship building skills. (Required proficiency)
• Ability to function independently and as a team player in a fast-paced environment. (Required proficiency)
• Must have strong written and verbal communication skills. (Required proficiency)
• Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e. printers, copy machine, FAX machine, etc.). (Required proficiency)
• Demonstrated ability to apply concepts, utilize sound judgment and work independently within a framework of guidelines. (Required proficiency)
• CM software proficient. (Preferred proficiency)

Licenses and Certifications

• Registered Nurse (RN), Ohio and/or Multi State Compact License (Required Upon Hire)

Physical Demands

• Standing Occasionally
• Walking Occasionally
• Sitting Constantly
• Lifting Rarely 20 lbs
• Carrying Rarely 20 lbs
• Pushing Rarely 20 lbs
• Pulling Rarely 20 lbs
• Climbing Rarely 20 lbs
• Balancing Rarely
• Stooping Rarely
• Kneeling Rarely
• Crouching Rarely
• Crawling Rarely
• Reaching Rarely
• Handling Occasionally
• Grasping Occasionally
• Feeling Rarely
• Talking Constantly
• Hearing Constantly
• Repetitive Motions Frequently
• Eye/Hand/Foot Coordination Frequently

Travel Requirements

• 10%