Denials Manager RN

AHMC Healthcare•San Gabriel, CA

1d•Onsite

About The Position

The Denials Case Manager, RN appeals all denials using InterQual criteria and medical necessity. This role involves collaborative work with all members of the revenue cycle team and various types of payers to resolve denials, maximize accurate and timely reimbursement, and perform reimbursement recovery and retention services. The manager evaluates, tracks, and trends denials, and implements denial prevention programs. They work in collaboration with Case Managers, Physicians, Finance, and multidisciplinary teams to ensure compliance with documentation and provide education as needed. This position requires the full understanding and active participation in fulfilling the Mission of San Gabriel Valley Medical Center, demonstrating behavior consistent with Core Values, and supporting the strategic plan and Performance Improvement Plan. The role is expected to advocate for the patient while balancing the responsibility of stewardship for their organization and the judicious management of resources, consistent with the American Case Management Association Standard of Practice. The position also requires an understanding of Medicare's definition of Medical necessity.

Requirements

Graduate of an accredited RN School of Nursing
Four years recent acute care experience in a critical care setting
Two years Utilization Management/Case Management experience
Working knowledge of MCG, Intensity of Service/Severity of Illness criteria.
Working knowledge of Title XXII and Title XIX.
Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, Shared Risk, and Managed Care.
Ability to negotiate with the physicians, payers, and customers.
Ability to track outcomes and report findings.
Able to problem solve effectively.
Ability to use clinical knowledge to identify potential quality issues.
Provides proper notification of absence or tardiness within established departmental time frames.
Current California RN License
Current BLS Card

Nice To Haves

BSN preferred

Responsibilities

Ensures template for appeals includes reason for denial, diagnosis codes, MCG criteria used to support appeal, highlights of medical necessity supporting appeal, and only supporting documents necessary to support appeal are submitted with appeal template.
Has knowledge of appeal deadlines and ensures appeals are submitted within this timeframe. Tracks responses to appeals, follows-up as appropriate.
Working knowledge of levels of appeals, time lines, and contractual requirements related to appeals.
Works with payers to resolve issues related to underpayments or increased denial trends.
Ensures working knowledge of contracts to ensure appropriate reimbursement.
Works closely with facility department directors such as Admitting, Case Management, Patient Accounting and CBO Directors to review, resolve and streamline all necessary aspects of the appeals process.
Establish appropriate tool for measuring Denial Tracking and Trending. Tracks and trends data, identifies opportunities for improvement, and establishes process improvement strategies as appropriate.
Works closely with Case Managers regarding the Peer to Peer process for concurrent denials. Ensures they are completed within timeframes and logged. Creates a peer to peer report on weekly/monthly basis for presentation at denials meetings.
May be asked to provide education and training to the Medical Staff, Nursing staff and or others related to denial prevention.
Leads in RAC preparedness and assists facility in the time of RAC Audits.
Participates in Continued Education in current laws that prevent unlawful denials, California Code of Regulations and HMO Compliance. Attends training and develops relevant knowledge and skills related to any identified gaps.
Participates in all Corporate and Facility based Denials Meeting.
Participates in Utilization Management and other meetings regarding denials, and audits as necessary.
Other responsibilities deems necessary as delegated. regarding denials and denials prevention.
Performs other duties as assigned.