Denials Management RN

California Region • Rancho Cordova, CA

3d • $78 - $104

About The Position

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.

Requirements

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

Nice To Haves

• 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

• 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.

What This Job Offers

• Career Level: Mid Level
• Education Level: Associate degree