Denials Management Specialist (Registered Nurse (RN) License Required)

St. Luke’s University Health Network•Allentown, PA

1d•Onsite

About The Position

The Denials Management Specialist RN is responsible for reviewing clinical documentation and payer denials related to inpatient hospital stays to determine and articulate medical necessity. This role involves writing comprehensive and evidence-based appeal letters for inpatient denied claims, including readmissions, late pick-up and level of care denials, ensuring compliance with payer guidelines, regulatory requirements, and organizational policies. Reviews Inpatient CMS and Third-Party denials for medical necessity and tracks outcomes regarding appeal process.

Requirements

Graduate of an accredited professional nursing program.
Registered nurse with current license to practice in the state.
Minimum of 2-5 years of clinical nursing experience in an acute care hospital setting required.
Experience in the use of computer applications, and statistical analysis using a variety of tools such as EXCEL, EPIC reporting, and MSOffice, etc. required.

Nice To Haves

2-5 years’ experience in case management and/or utilization management preferred.
Appeal writing experience and financial experience related to appeal processes with insurance providers preferred.

Responsibilities

Reviews all Inpatient Retroactive Denials in the Denials Management Work Queues for Medical Necessity, Late-Pick-Up/Notification and Readmission Denials that are entered by Utilization Review and Business Office.
Responsible for writing appeal letters for Inpatient CMS (RAC/MAC) and Commercial late pick-ups, medical necessity, readmissions, and other requested inpatient denials as deemed clinically appropriate.
The DS RN is responsible for reviewing clinical documentation and payer denials related to inpatient hospital stays to determine and articulate medical necessity.
This role involves writing comprehensive and evidence-base letters for Inpatient Denials ensuring compliance with payer guidelines, regulatory requirements, and organizational policies.
Maintain accurate documentation of all appeal activities within designated systems.
Maintains accurate spreadsheets for retro denials to ensure resolution within required timeframes and logging of action e.g. no appeal, appeal level and final decision with revenue impact.
Assists Utilization Review as necessary to ensure that documentation is entered and transmitted to insurance carriers within acceptable timeframes to comply with appeal deadlines.
Provides feedback to Utilization Review that can help in preventing future denials and assists in maintaining good communication and process flow between the 2 departments.
Track and monitor denials and appeal outcomes to identify trends and opportunities for process improvement.
Participates in root cause analysis for overturned and upheld appeals.
Works with departments and providers to implement corrective actions to minimize lost revenue due to denials and rejections.
Coordinates RAC appeals for complex case reviews for medical necessity, including determining if appeal is appropriate and communicating with vendor to ensure timely filing of same.
Performs writing of RAC/MAC appeals at appropriate levels and documenting status.
Maintains confidentiality of all materials handled within the Network/Entity as well as the proper release of information.
Complies with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements.
Demonstrates/models the Network’s Service Excellent Standards of Performance in interactions with all customers (internal and external).
Demonstrates Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety.
Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.
Complies with Network and departmental policies regarding attendance and dress code.
Demonstrates competency in the assessment, range of treatment, knowledge of growth and development and communication appropriate to the age of the patient treated.
Stays abreast of CMS and payer guidelines, regulatory requirements, and organizational policies impacting the revenue cycle regarding medical necessity.
Maintains relationships with third party medical review staff and other departments to assist in adjudicating cases.
Other related duties as assigned.