Denials & Appeals Specialist, Nurse - Full-time / Part-time

Summary: Support CHS hospitals with appeals of health plan medical necessity, authorization and level of care denials. Review all assigned inpatient denials; obtain additional information as needed to file clinical appeals necessary to resolve payor denial of reimbursement on inpatient, outpatient or observation claims. Communicate clinical denial information to appropriate departments and/or personnel for follow up and educational purposes. Maintenance and upkeep of inpatient denial pools and documents as required.

Essential Duties and Responsibilities include the following: (Other duties may be assigned).

File medical necessity and level of care appeals u sing InterQual and CMS guidelines .

Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures.

Track and manage clinical denials using current tools (manuals, training programs). Identify patterns and trends in denials; communicate to appropriate persons. Maintain documentation regarding all payor resources regarding denials and appeals processes.

Observe professional ethics in maintaining confidential information acquired concerning the personal, financial, medical or employment status of patients (and their families) provided services by the hospital.

Follow and enforce accepted safety practices for patients and the hospital. Report safety hazards and initiate appropriate action.

Participate in safety instructional programs

Observe excellent customer service skills when dealing with patients, families and/or significant others, outside vendors, coworkers, and physicians. Attend both mandatory and elective educational offerings to enhance professional performance.

Provide education to staff as appropriate. Perform additional duties as assigned or requested.

ESSENTIAL RCSC FUNCTIONS :

Understanding of the revenue cycle and the responsibility and goals of each area and how they impact the revenue cycle

Maintain knowledge of Business Office policies and procedures

Document all actions accordingly by documentation standards within Artiva, HMS and other business office systems as required.

Communicate with all parties in a professional manner to alert specific problem issues

Ensure confidentiality of all patient accounts by following HIPAA guidelines

Adheres to compliance of CMS and other payor guidelines

Attend in-services, education sessions and department meetings as scheduled

EDUCATION, SKILLS & EXPERIENCE:

Must have diploma/degree from an accredited school of nursing. LPN or RN with current license to practice in state.

Desirable characteristics include 5 years of clinical nursing experience. Utilization review and/or case management experience preferred. Ability to use initiative and independent judgment in decision making. Must be able to interact with all levels of hospital administration, physicians and other healthcare team members. Must be able to follow directions and perform work according to departmental standards and must be able to function effectively under stressful conditions. Excellent writing and communications skills as well as effective organizational skills a must.

Physical Demands:

The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Computer Skills:

To perform this job successfully, an individual should have intermediate knowledge of Microsoft Office Tools (Outlook, Excel, Word and PowerPoint) in addition to hospital patient accounting and billing systems.