Specialist-Denial II RN

Baptist•Memphis, TN

18d

About The Position

The Denial Mitigation-Appeal Specialist II RN plays a key role in the BMHCC revenue cycle. The specialist reviews clinical information and supporting documentation for acute care inpatient services and other assigned account classes to determine appeal actions and other next steps, including completing level-of-care downgrades for billing or clinical purposes, identifying escalation options, participating in clinical meetings, contacting payers, obtaining additional documentation from physician clinics, and collaborating with coding and billing teams on appeals, corrected claims, and denial resolution. The role includes reviewing payer denials, thoroughly analyzing patient clinical records, and preparing clinical timelines and account summaries. The specialist compiles appeals with pertinent clinical and financial information for healthcare insurance providers in response to post-claim denials. Communication with a Physician Advisor may be needed for additional clinical review. The specialist follows accounts through the appeal process, determines when escalation to a manager or payer is appropriate, and may defend appeals in payer hearings or clinical meetings. The position reports to the Manager of the Denial Mitigation Department and includes other duties as assigned. Remote work may be available after 90 days if productivity requirements and training goals are successfully met, as determined by the Manager or Director of the Denial Mitigation Department.

Requirements

RN with five years of clinical experience in an acute healthcare setting.
In addition to acute-care clinical experience, one or more of the following: 3–5 years of insurance provider, auditing, or medical review experience involving denied claims (such as authorizations, claims review, patient billing, appeal writing, auditing, or denial management); 3–5 years of case management experience; or other related relevant experience.
Graduate of an accredited nursing program.
Training in nursing, case management, or denial management.
Familiarity with electronic medical records and claims or practice management systems.
Critical thinking and judgment, including the ability to appropriately use standard criteria established by payers.
Excellent interpersonal, communication, and writing skills.
Advanced computer literacy, including the ability to type and key accurately.
Strong analytical and problem-solving skills, including the ability to understand and troubleshoot interconnected data and denial processes.
RN licensure.
Ability to meet departmental quality and productivity standards.

Nice To Haves

CCM certification.
CCS certification.

Responsibilities

Review, assess, and evaluate communications and correspondence to optimize reimbursement.
Evaluate clinical information and supporting documentation before initial appeal action.
Review extenuating circumstances and outside variables from point of entry through discharge when responding to technical authorization denials.
Compile, analyze, and distribute pertinent clinical and financial information to healthcare insurance providers in response to post-claim denials.
Prepare denial responses using medical-record clinical information, payer policies, NCDs, LCDs, and state and federal rules and regulations.
Submit retro-authorization requests, reconsiderations, and appeals in accordance with payer-specific deadlines, contractual agreements, and preferred submission methods.
Build knowledge of external appeals, hearings, and escalation options outside the formal appeal process.
Work with the Physician Advisor on medically complex case appeals, hearings, or level-of-care issues.
Report denial trends to management to improve performance and awareness of resources used in relation to reimbursement.
Complete assigned goals and projects within designated timeframes.
Meet departmental quality and productivity standards.
Use strong prioritization, organization, and written and verbal communication skills in carrying out the role.
Use knowledge of payer guidelines, BMHCC contracts, authorization and clinical denials, clinical audits, and payer portals to obtain information for appeal submissions.