RN Denial Management Specialist

Banner Health•Phoenix, AZ

2d•$37 - $62•Remote

About The Position

This position is responsible for providing support to the organization’s Recovery Audit Contractor (RAC) program by reviewing clinical information and auditing billings to determine appropriateness of charges in accordance with CMS standards. In addition, this position provides oversight for the company’s retrospective denial management process. This position promotes continual efforts to further the understanding of the complexities of federal, state and commercial regulatory coordination and provides leadership assistance to achieve optimal clinical, operational, financial, and satisfaction outcomes across the system as related to reimbursements.

Requirements

Requires Registered Nurse (R.N.) licensure in the state of practice.
Requires experience in federal, state and commercial reimbursements and in reviewing clinical information typically acquired in three years auditing DRG coding and reimbursements.
Requires five or more years of clinical nursing and/or related experience.
Experience in evaluation techniques, teaching, hospital operations, reimbursement methods, medical staff relations, and the charging/billing process is required.
A working knowledge of utilization management and patient services is required.
A working knowledge of Medical and third party payor requirements and reimbursement methodologies is required.
Highly developed human relation and communication skills are required.
Must demonstrate critical thinking, problem-solving, effective communication, and time management skills.
Must demonstrate ability to work independently as well as effectively with team members.
Must be proficient in the use of office desktop software programs.

Nice To Haves

BSN preferred.
Additional related education and/or experience preferred.
Preferably in Case Management and/or Utilization Review.

Responsibilities

Provides clinical expertise and oversight in the determination of the clinical appeals and denial management process resulting in significant savings for the organization.
Serves as a resource to the company’s RAC team in responding to audit requests and serves to expedite the disposition of claims by reviewing charts and preparing appeals.
Authorizes the appropriate write off of claims that do not meet criteria for hospitalization.
Serves as primary educator for staff and physicians on regulatory compliance measures and in the use of clinical system criteria.
Evaluates and intervenes retrospectively for coverage issues, payor outliers, split billing, disallowed charges, incorrect DRG codes, denial and compliance issues.
Quantifies, analyzes, and monitors industry/Medicare trends in order to reduce denials and improve the financial outcomes for the organization.
Makes recommendations for improvements based on these trends.
Serves as a resource and provides leadership assistance to achieve optimal clinical, operational, financial, and satisfaction outcomes across the system as related to federal, state and commercial reimbursements.
Acts as a consultant across the organization to facilities with questions related to proper use of DRG codes.
Supports change and participates in the development, implementation and evaluation of the goals/objectives and process improvement activities across the organization as related to federal, state and commercial reimbursements.
Corporate based position with no budgetary responsibility.
Internally, this position interacts with physicians, clinicians correct and management across the system.
Externally, this position interacts with RAC Auditors and other organizations.