RN Clinical Reimbursement Specialist

INTEGRIS Health•OK, OK

12d•Onsite

About The Position

The RN Clinical Reimbursement Specialist identifies and prepares clinical appeals for government payors, managed care organizations, and other payors. The role also provides assistance and guidance in maintaining the charge description master for the INTEGRIS Health system. It oversees the system’s clinical denial management process, supports revenue recovery and hospital departments with clinical expertise, and works across departments to address denial, charging, coding, and documentation issues. The position reports to an assigned Corporate Manager.

Requirements

Current Oklahoma licensure as a Licensed Practical Nurse (LPN) or Registered Nurse (RN), or a current multistate license from a Nurse Licensure Compact (eNLC) member state.
The posting lists 8 years of experience working with healthcare facilities, health insurance, or managed care companies and 10 years of demonstrated experience in those areas.
6 years of direct managed care or case management experience.
Knowledge of government rules and regulations, managed care contracts, provider relations, pre-certification, reimbursement, financial analysis, and patient accounting.
Knowledge of legal documents, collection agency procedures, and contract documents.
Ability to communicate effectively in English, verbally and in writing.

Responsibilities

Assist the Director of Revenue Recovery with training and developing INTEGRIS recovery staff on clinical and non-clinical payment issues.
Oversee and manage the INTEGRIS system clinical denial management process.
Identify inaccurate or problematic denial and payment trends and help develop plans to maximize facility reimbursement.
Participate in Utilization Management Committees for INTEGRIS facilities, reporting denial issues and developing preventive strategies in collaboration with physicians.
Analyze, prepare, and distribute monthly denial reports to designated hospital department Vice Presidents, Directors, and Managers.
Respond to utilization management clinical denials issued by government-contracted vendors for Medicare and Medicaid programs.
Support Case Management and other hospital departments with clinical expertise on payor and patient clinical denial inquiries.
Assist the Chargemaster Consultant with development, implementation, maintenance, and auditing related to the chargemaster description master.
Analyze denial trends for documentation or charging opportunities and facilitate cross-departmental collaboration to improve processes and develop best practices.
Identify charging, coding, or clinical documentation issues; work with ancillary departments to resolve them and notify appropriate leadership.
Maintain effective and practical knowledge of government and managed care payer rules, regulations, and requirements.