Specialist-Denial II RN

Baptist•Memphis, TN

2d•Hybrid

About The Position

The Denial Mitigation-Appeal Specialist II RN serves in a key role of the BMHCC revenue cycle. This role involves performing reviews of clinical information and supporting documentation for acute care inpatient services and other account classes to determine appeal and/or other actions. These actions include complete level of care downgrades for billing/clinical purposes, identifying further escalation options, participating in clinical meetings, reaching out to payer contacts, and communicating with physician clinics to obtain additional documentation to support appeals. The specialist collaborates with coding/billing for the formulation of appeals with corrected claims and denial resolution to defend revenue. The Denial Mitigation-Appeal Specialist II RN reviews denials received from payers, completes a thorough analysis of the patient’s clinical record, and prepares a clinical timeline and summary of the account to determine next steps. In accordance with guidelines, the Specialist compiles an appeal along with pertinent clinical and financial information to send to healthcare insurance providers in response to post-claim denials. Physician Advisor communication may be necessary for further clinical review from a physician's perspective in preparation of writing the appeal. The specialist follows the account throughout the entire appeal process and determines if escalation to a manager or payer is the next step to achieve a favorable outcome. The specialist may be required to defend appeals in payer hearings or clinical meetings. The Denial Mitigation-Appeal Specialist II RN may have the opportunity to work remotely after 90 days upon successfully meeting productivity requirements and training goals as determined by the Manager/Director of the Denial Mitigation Department. This role reports to the manager of the Denial Mitigation Department and performs other duties as assigned.

Requirements

RN with 5 years clinical experience in acute healthcare setting and one or more of the following: 3-5 years insurance provider, auditing, or medical review experience performing activities related to denied claims such as obtaining authorizations, claims review, patient billing, appeal writing, auditing, and/or denial management; 3-5 years case management experience, or other related relevant experience.
Graduate of an accredited nursing program
Nursing, Case Management or Denial Management.
Familiarity with electronic medical records and claims/practice management systems.
Requires critical thinking and judgement and must demonstrates the ability to appropriately use standard criteria established by payers.
Excellent interpersonal, communication, and writing skills.
Advanced computer literacy skills.
Strong analytical and problem solving skills with an ability to understand and troubleshoot interconnected data and denial processes.
Excellent communication skills.
Advanced computer literacy skills with the ability to type and key accurately.
RN

Nice To Haves

Responsibilities

Requires strong prioritization, organization, and both written and verbal communication skills.
Requires extensive knowledge of payer guidelines and BMHCC contracts as it pertains to authorization and clinical denials as well as clinical audits.
Requires a strong foundation and knowledge of payer portals and demonstrates the skill set in obtaining information from the payer for appeal submission.
Must be able to meet quality and productivity standards as identified by the department.
Reviews, assesses, and evaluates all communications/correspondences received in order to optimize reimbursement.
Evaluates clinical information and supportive documentation prior to initial appeal action in order to optimize reimbursement and utilization of resources.
Meticulously reviews extenuating circumstances and other outside variables from point of entry to discharge when responding to technical authorization denials.
Compiles, analyzes, and distributes pertinent clinical and financial information to healthcare insurance providers in response to post-claim denials received by BMHCC.
Prepares response to denials based on supporting clinical information in the medical record, applicable payer policies, NCDs, LCDs, and state and federal rules and regulations in order to enhance reimbursement and maximize customer satisfaction.
Submits retro-authorization requests, reconsiderations, and appeals with careful regard to payer specific timeframes, contractual agreements, and preferred method of submission.
Utilizes and builds knowledge base with regard to external appeals, hearings and escalation options outside the formal appeal process.
Works closely with physician advisor for assistance with medically complex case appeals, hearings, or level of care issues.
Reports denial trends to management in order to improve performance, and increase awareness of resources consumed with relation to reimbursement.
Completes assigned goals and projects within designated timeframe.