Denials & Appeals Administrator (RN)

BMC Software

3d•$43 - $63•Onsite

About The Position

The RN Appeal Administrator will be responsible for the Pre-denial/ Denial and appeal process in addition to Utilization Review, to validate the patient’s placement to be at the most appropriate level of care based on nationally accepted admission criteria. The Appeal/ UR Administrator uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay. The Appeal/ UR Administrator secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required. The Appeal/ UR Administrator follows the UR process, in addition to the pre-denial and denial/appeal process as defined in the attached job description and in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review. The Denials and Appeals Administrator assesses, plans, coordinates, and evaluates initial and ongoing denials. He/She obtains information on all denials occurring as related to observation and inpatient stays. The Denials and Appeals Administrator researches and responds to denials in a timely fashion. He/She communicates with multiple members of the clinical team in clear concise language taking the lead in the resolution of the clinical denials. He/ she identifies trends and responds to the trends by recommending changes in practice and or documentation of the clinical providers to promote a reduction in the denials trends. The Denials and Appeals Administrator collects and trends the data for the return on investment as it relates to denials and reports that data to the Director Care management for review. The Denials and Appeals Administrator combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Collaborates with physicians, Case Managers, revenue cycle personnel and payers to appeal denials. Performs activities related to insuring a denial appeals process that includes monitoring for patterns and trends and maximizing reimbursement within regulatory requirements.

Requirements

Licensed to practice professional nursing as a registered nurse in the Commonwealth of Massachusetts.
Minimum 5 years or more related experience preferably in a healthcare case management and patient insurance/billing environment.
Medical records coding experience is desirable.
Comprehensive knowledge of clinical documentation and medical coding.
Working knowledge of patient financial billing regulations/requirements, reimbursement, and managed care.
Ability to review, interpret, and analyze clinical and patient financial reports and data.
Ability to plan, coordinate, and prepare for corrections to accounts.
Advanced interpersonal skills necessary to work with physicians, hospital directors, and managers to affect changes in clinical and fiscal operations, policies, and procedures.
Ability to provide guidance, communicate, and interpret complex patient billing and compliance information.
Must be vaccinated against COVID-19 and flu, and receive a booster dose of the COVID-19 vaccine.

Nice To Haves

Graduate degree preferred.
3-4 years supervisory experience preferred.

Responsibilities

Validate patient's placement at the most appropriate level of care based on nationally accepted admission criteria.
Use medical necessity screening tools (e.g., InterQual, MCG criteria) for initial and continued stay reviews.
Determine appropriate level of patient care, appropriateness of tests/procedures, and estimate expected length of stay.
Secure authorization for clinical services through collaboration and communication with payers.
Follow UR process, pre-denial, and denial/appeal process in accordance with CMS Conditions of Participation for Utilization Review.
Assess, plan, coordinate, and evaluate initial and ongoing denials.
Obtain information on all denials related to observation and inpatient stays.
Research and respond to denials in a timely fashion.
Communicate with clinical team members to resolve clinical denials.
Identify trends in denials and recommend changes in practice or documentation to reduce them.
Collect and trend data for return on investment related to denials and report to Director Care Management.
Combine clinical, business, and regulatory knowledge to reduce financial risk from denials.
Collaborate with physicians, Case Managers, revenue cycle personnel, and payers to appeal denials.
Monitor for patterns and trends in denial appeals and maximize reimbursement within regulatory requirements.