Registered Nurse Denial Appeals Lead

McLaren Health Care • Michigan, ND

57d

About The Position

Position Summary: Responsible for assisting the Corporate Director of Denials Management in the coordination of day-to-day operations and workflow of the Denials team. The objective is to ensure quality outcomes and revenue integrity through coordination, collaboration, and communication with related disciplines to address and integrate opportunities for denial appeals. Essential Functions and Responsibilities as Assigned: 1. Assists in ensuring day-to-day activities of the Denial Appeal department are conducted in an accurate and timely manner. Assists with the coordination of staff assignments and vendor tool management. 2. Assists with writing appeal letters, when indicated, pertaining to RAC/3rd party payers' disputes/overpayments. Appeal letters will include compelling factual argument and submit to insurance payer requesting timely payment for services. 3. Assists in running reports and utilizes tools (i.e., MHC Data Warehouse, level of care (LOC), Optum, Veracity, CBO MHC Denials Dashboard) for reporting trends and identifies opportunities for potential denials management impact on medical necessity and DRG denials 4. Conducts patient medical record reviews and utilizes clinical knowledge to determine why cases are denied and whether an appeal is required. Confers with physician and management when needed, regarding appeal status. 5. Assesses and presents education opportunities for Denial Appeal staff and physicians. Communicates with and educates all members of the patient care team. Educates health team colleagues about complex clinical appeals/denials, utilization review, including role, responsibilities tools, and methodologies.

Requirements

• State licensure as a Registered Nurse (RN)
• Bachelor's degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position.
• Three years of recent denial management, case management, clinical documentation, or utilization review experience
• Five years of clinical nurse experience in an acute care setting
• American Case Management Certification (ACM) or obtain certification when eligible as defined by the Association Case Management Association, and maintenance of continuing education requirements

Nice To Haves

• Experience in utilization management/case management/clinical documentation.
• Certification in Case Management (ACM or CCM)

Responsibilities

• Assists in ensuring day-to-day activities of the Denial Appeal department are conducted in an accurate and timely manner. Assists with the coordination of staff assignments and vendor tool management.
• Assists with writing appeal letters, when indicated, pertaining to RAC/3rd party payers' disputes/overpayments. Appeal letters will include compelling factual argument and submit to insurance payer requesting timely payment for services.
• Assists in running reports and utilizes tools (i.e., MHC Data Warehouse, level of care (LOC), Optum, Veracity, CBO MHC Denials Dashboard) for reporting trends and identifies opportunities for potential denials management impact on medical necessity and DRG denials
• Conducts patient medical record reviews and utilizes clinical knowledge to determine why cases are denied and whether an appeal is required. Confers with physician and management when needed, regarding appeal status.
• Assesses and presents education opportunities for Denial Appeal staff and physicians. Communicates with and educates all members of the patient care team. Educates health team colleagues about complex clinical appeals/denials, utilization review, including role, responsibilities tools, and methodologies.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Hospitals
• Number of Employees: 5,001-10,000 employees