Registered Nurse - Denial and Appeals Coordinator - Days

Full Time (80 Hours Biweekly)

Day Shift

Job Description:

Under direct supervision this position manages the denials in Case Management related to medical necessity. Assist in collection and trending of data to identify areas of improvement. Successfully appeal and recover funds due to the organization, in collaboration with the physician advisor. Develops and implements standard work, as well as implementing lean principles to reduce waste.

Duties and Responsibilities

Essential Accountabilities:

1. Coordinates denial management activities to successfully appeal and recover monies for the organization.
2. Under guidance of the Physician Advisor writes appeal letter and coordinates with administrative staff to obtain the medical record and mailing to insurance company.
3. Collaborates with Payer Reimbursement Analyst to ensure timely follow up on the status of appeal. Follow through until appeal rights have been exhausted.
4. Daily review of Medicare One Day Stay Workque to ensure compliance with Two Midnight Rule. Take necessary action to the accounts that cannot be billed as Inpatient.
5. Reviews Medical Assistance Workques to identify and prioritize reviews based on Department of Public Welfare (DPW) timeframe. Facilitates all Medical Assistance reviews by completing the medical necessity form and submitting to DPW.
6. Interfaces with Payer Contracting Department regrading issues identified with Managed Care companies.
7. Maintains an understanding of the patient access and patient finance components within EPIC.
8. Maintains an understanding of payer reimbursement to include third-party payers and governmental agencies such as Medicare, Medicaid, and Tricare.
9. Maintains an understating of all Managed Care agreements and contracted rates.
10. Evaluates denials to determine root cause and reports this information to system Case Management Leadership.
11. Serves as a resource to Payer Reimbursement Team and Patient Finance relative to the utilization management process and medical necessity.
12. Documents all activities in individual patient accounts within the EPIC medical record.
13. Completes other projects as assigned.

NonEssential Accountabilities:

1. Attends meetings as required.
2. Performs other related duties as identified.

Common Expectations:

1. Maintains established policies and procedures, objectives, quality assessment and safety standards.
2. Participates in educational programs and in-service meetings.
3. Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

Qualifications

• Minimum Experience:
  • :3-5 years
• Minimum Education:
  • :Associate degree in Nursing
• Minimum Field Of Expertise:
  • :Utilization management, case management
• Preferred Education:
  • : Bachelor’s degree in Nursing
• Required Certification:
  • Registration and current RN license in PA