RN Clinical Reimbursement Specialist

INTEGRIS Health•OK, OK

1d•Onsite

About The Position

The RN Clinical Reimbursement Specialist supports the RN Clinical Denials team at the INTEGRIS Health 5300 Building in Oklahoma City, Oklahoma. The role identifies and prepares clinical appeals for government payors, managed care organizations, and other payors, and provides assistance and guidance in maintaining the INTEGRIS Health system’s charge description master. It oversees the system clinical denial management process, analyzes denial and payment trends, supports reimbursement improvement and collaborates with clinical and operational departments to resolve 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.
Eight years’ experience working with healthcare facilities, health insurance, or managed care companies, and ten years’ demonstrated experience working with healthcare facilities, health insurance, or managed care companies (as stated in the posting).
Six years of direct managed care or case management experience.
Knowledge and proficiency in 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 development of 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, report denial issues, and collaborate with physicians on preventive strategies.
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 Medicare and Medicaid vendors.
Support Case Management and other hospital departments with clinical expertise for payor and patient clinical denial inquiries.
Assist the Chargemaster Consultant with development, implementation, maintenance, and audits 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, practical knowledge of government and managed care payer rules, regulations, and requirements.