Denial and Appeals RN / Clinical Resource Management

Hartford Healthcare•Wethersfield, CT

4d•Hybrid

About The Position

The Denial and Appeals Nurse is an integral part of the Care Management team. Their focus is on the management of the payer denial and appeals process. The Denial and Appeals Nurse is responsible for appealing inappropriate denials through all levels of the appeals process. The Denial and Appeals Nurse is able to work autonomously and swiftly, managing a high volume of complex cases across all HHC system hospitals.

Requirements

Registered Nurse
Current State of Connecticut RN license is required
Five years of relevant case management, utilization management or managed care experience
Strong interpersonal and written / oral communication skills
Maintains a positive attitude in a fast-paced environment
Able to influence and negotiate
Critical thinking, astute assessment and confident in decision making
Knowledge of Interqual, MCG, or equivalent criteria and reimbursement guidelines
CT RN license required without restriction, to the extent allowed by State and Federal law.
Use of Microsoft Office including Word, Excel, and Power Point
Use of EPIC

Nice To Haves

Bachelors of Science in Nursing is preferred
Thorough understanding of Medicare, Medicaid, and Commercial reimbursement methodologies is preferred
CCM (certified case manager), CPUM (certified professional in utilization management), or other relevant certification is preferred

Responsibilities

Follow standard work processes to manage denials and appeals
Ensure activities are completed within regulatory and payer timeframes
Develop and maintain collaborative relationships with internal and external stakeholders as needed to obtain additional information to properly formulate the clinical appeal and to resolve any issues that may arise during the appeals process
Partner with the Medical Director and Physician Advisor staff to compose factually sound appeal letters for denial reconsiderations utilizing clinical documentation and contract language
Maintain all documentation associated with the processing and handling of appeals to comply with regulatory standards and timeframes while maintaining an accurate, complete appeals record in the appropriate database
Assist in analysis and documentation of root cause for denials
Provide education to stakeholder groups on findings, analysis and mitigation strategies as needed
Work with multi-disciplinary team to identify denial / appeal trends and supports development of performance improvement strategies in response to identified patterns
Other duties as assigned.