Denials Management RN

CommonSpirit Health•Rancho Cordova, CA

1d•Onsite

About The Position

Dignity Health, one of the nation’s largest health care systems, is a 22-state network of more than 9,000 physicians, 63,000 employees, and 400 care centers, including hospitals, urgent and occupational care, imaging and surgery centers, home health, and primary care clinics. Headquartered in San Francisco, Dignity Health is dedicated to providing compassionate, high-quality, and affordable patient-centered care with special attention to the poor and underserved. As our Denials Management RN, you will be responsible and accountable for receiving, processing, and documenting all concurrent denials for assigned facilities, providing clinical expertise within the revenue cycle. Every day, you will perform root cause analysis of concurrent denials, formulate and implement plans to address specific causes, and identify process gaps leading to denials. You will document and communicate findings to management, and recommend/provide education in collaboration with your manager. You will follow a standardized approach to managing denials to achieve organizational objectives of financial stewardship and patient advocacy through accurate billing. You will use professional judgment, independent analysis, and critical-thinking skills to apply clinical guidelines, policies, and payer knowledge for the best financial outcome. To be successful in your role, you will strategically manage and resolve concurrent denials, leveraging your clinical expertise to conduct root cause analysis, identify process gaps, and implement effective solutions for assigned facilities. You will demonstrate exceptional analytical skills, meticulous documentation, and a strong commitment to financial stewardship and patient advocacy, all while adhering to organizational values and continuously improving revenue cycle integrity through accurate billing and education. Determines appropriate admit status for concurrently denied hospital stays, using utilization management guidelines, medical necessity criteria, critical thinking skills, and physician advisor review. Identifies denial root cause for each individual concurrent denial. Determines appropriate denial resolution strategy based on individual payer policies. Implements strategies, such as RN reconsideration and peer to peer physician review. Escalates challenging cases and concerning payer trends to Leadership. Documents findings and determinations in electronic medical record or denial software.

Requirements

Minimum three (3) years clinical experience as Registered Nurse (RN)
California RN license

Nice To Haves

Bachelors
Graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN) or related healthcare field)
5 years of RN experience
Three (3) years utilization management experience
Denials management experience
Certified Case Manager
Accredited Case Manager

Responsibilities

Receiving, processing, and documenting all concurrent denials for assigned facilities
Providing clinical expertise within the revenue cycle
Performing root cause analysis of concurrent denials
Formulating and implementing plans to address specific causes of denials
Identifying process gaps leading to denials
Documenting and communicating findings to management
Recommending and providing education in collaboration with your manager
Following a standardized approach to managing denials
Using professional judgment, independent analysis, and critical-thinking skills to apply clinical guidelines, policies, and payer knowledge
Strategically managing and resolving concurrent denials
Conducting root cause analysis
Identifying process gaps
Implementing effective solutions for assigned facilities
Determining appropriate admit status for concurrently denied hospital stays
Identifying denial root cause for each individual concurrent denial
Determining appropriate denial resolution strategy based on individual payer policies
Implementing strategies, such as RN reconsideration and peer to peer physician review
Escalating challenging cases and concerning payer trends to Leadership
Documenting findings and determinations in electronic medical record or denial software