Denial Prevention Nurse Consultant

Revecore•Remote,

4d•Remote

About The Position

Revecore is seeking a Denial Prevention Nurse Consultant to join their team. This role is primarily responsible for reviewing medical records and documentation to determine appropriate billable services for hospitals, constructing appeals for payment based on medical necessity or payer-specific guidelines. The consultant will also provide clients with trending, revenue cycle fail point analysis, and best practice remediation recommendations. Revecore offers a collaborative and diverse culture with a great work/life balance, powered by people and driven by technology.

Requirements

College degree or diploma from school of nursing -- must be RN
Clinical nursing experience working in hospital environment, preferably in ER, Critical Care or diagnostic services
Minimum 5 years of related experience and/or training in utilization review or patient accounting
Highly proficient with Interqual and MCG guidelines and demonstrate appropriate application to claim appeal argument.
Understand patient accounting documents -- UB04, EOB
Have a working knowledge of Microsoft Office (Word, Excel, Outlook)
Possess technical proficiency to work on multiple computer screens and software applications simultaneously
Able to read and interpret an extensive variety of documents such as medical records, patient care systems, instructions, policies and procedures in written (in English) and diagram form
Can maintain strong performance in a fast-paced environment with productivity metrics
Strong analytical skills, attention to detail, and problem-solving skills to identify underpayments and discrepancies
Experience with healthcare billing software and databases (EPIC, Cerner, Meditech)

Responsibilities

Build strong, lasting relationships with clients, payors and Revecore personnel
Analyze medical records or other medical documentation to validate services, tests, supplies and drugs performed for accuracy related to billing for services rendered
Identify and interpret medical, radiological, laboratory or other tests and procedures as well as pharmaceutical drugs
Review and understand managed care contracts, hospital billing statements/bills and insurance denials
Research commercial and governmental payor policies, clinical abstracts and studies, and other documentation related to claims payment to evaluate and appeal denied claims.
Perform research regarding denials and effectively communicate information to associates, colleagues, managers and clients
Contact insurance company to obtain missing information, explain and resolve underpayments and/or denials and arrange for payment or adjustment processing on behalf of client
Prepare and submit correspondence such as letters, emails, online inquiries, appeals, adjustments, reports and payment posting
Perform denial trending for clients, identify fail points within the revenue cycle and on the payer side, and provide best practice recommendations to clients and Revecore managers.
Maintain regular contact with necessary parties regarding claims status including payors, clients, managers, and other Revecore personnel
Maintain confidentiality of information in compliance with company policy and HIPAA
Attend client, department and company meetings
Lead client meetings and perform consulting services to client's as it relates to medical necessity of services performed and proper vetting of payers criteria