Registered Nurse, RN-Denials and Appeals, FT Days

Prisma Health•Columbia, SC

About The Position

Inspire health. Serve with compassion. Be the difference. Job Summary Responsible for the coordination and resolution of the clinical observations inclusive of denials and appeals of the system-wide comprehensive. Performs the necessary audits to evaluate the revenue cycle process and educates staff on issues impacting reimbursement. Essential Functions All team members are expected to be knowledgeable and compliant with Prisma Health's purpose: Inspire health. Serve with compassion. Be the difference. Utilizing Prisma Health information systems, identifies and resolves accounts that have been improperly converted and denied by insurance carriers for clinical reasons. This includes researching observations, denied claims, applying acuity criteria, collaborating with departments, confirmation of LOC's processing and resolving the denial for appropriate payment. Facilitates the identification and resolution of in-house denials and appeals through effective collaboration with the Utilization Review / Outcomes Management department. Represents Prisma Health when interacting with payors in acuity and level of care issues. Monitors denial and appeals information for payor, provider or departmental trends. Routinely reports to management regarding trends and recommends process improvement initiatives. Regularly reviews aging appeals and problem cases. Produces denials and appeals tracking reports for Management and Departments. Provides comprehensive training for Prisma Health staff regarding denial resolution, appeals processing, process improvement and revenue cycle issues that impact reimbursement. Assists the Manager of Denials and Appeals Management and the Director of Reimbursement with the development of strategic goals relative to the reduction in denials volume. Maintains knowledge of current trends and developments in the healthcare industry and specifically as it relates to denials and appeals through appropriate literature and professional development activities. Performs other duties as assigned.

Requirements

Education - Associate degree in Nursing
Experience - Five (5) years Nursing experience in a hospital setting.
Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.

Nice To Haves

Experience in in-patient, out-patient or physician coding experience, revenue cycle and/or utilization management experience preferred

Responsibilities

Responsible for the coordination and resolution of the clinical observations inclusive of denials and appeals of the system-wide comprehensive.
Performs the necessary audits to evaluate the revenue cycle process and educates staff on issues impacting reimbursement.
Utilizing Prisma Health information systems, identifies and resolves accounts that have been improperly converted and denied by insurance carriers for clinical reasons.
Facilitates the identification and resolution of in-house denials and appeals through effective collaboration with the Utilization Review / Outcomes Management department.
Represents Prisma Health when interacting with payors in acuity and level of care issues.
Monitors denial and appeals information for payor, provider or departmental trends.
Routinely reports to management regarding trends and recommends process improvement initiatives.
Regularly reviews aging appeals and problem cases.
Produces denials and appeals tracking reports for Management and Departments.
Provides comprehensive training for Prisma Health staff regarding denial resolution, appeals processing, process improvement and revenue cycle issues that impact reimbursement.
Assists the Manager of Denials and Appeals Management and the Director of Reimbursement with the development of strategic goals relative to the reduction in denials volume.
Maintains knowledge of current trends and developments in the healthcare industry and specifically as it relates to denials and appeals through appropriate literature and professional development activities.
Performs other duties as assigned.