Specialist Denial Mgt

Independence Health System Careers • Greensburg, PA

8h • Hybrid

About The Position

This role is responsible for managing denial and appeal processes within the health system. The Specialist Denial Mgt will identify, coordinate, and manage plans for medical necessity-based denials, monitor denial trends, and facilitate appeals and grievances. This position requires a strong understanding of payer guidelines, clinical documentation, and the ability to communicate effectively with various stakeholders, including physicians, case managers, and revenue cycle teams. The goal is to reduce denials, improve the appeal process, and ensure compliance with payer regulations.

Requirements

• Graduate of an accredited Nursing Program required.
• Bachelor’s Degree in Nursing.
• Three (3) years clinical experience in healthcare/case management or Utilization Review experience.
• Strong leadership ability.
• Good organizational skills.
• Independent and critical thinking skills.
• Sound judgment.
• Knowledge of legal aspects and liability of nursing practice.
• Strong ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience.
• Functional Skills on PC and Related Software (Microsoft Office).
• Knowledge of basic Office Equipment such as copier, fax machine, etc.
• Proficiency in the use of Excel Spreadsheets, PowerPoint, and various software programs.
• Current licensure to practice as a Registered Nurse in the State of Pennsylvania required.
• Act 34-PA Criminal Record Check from the PA State Police System.

Nice To Haves

• Case Management Certification.
• Recent case management/denial and appeal experience.
• Masters Degree in Nursing or related healthcare field.
• Knowledge of Payer/Insurance Benefits.
• Working knowledge of InterQual ® Level of Care Criteria and other relevant medical necessity screening tools, including the Medicare Benefit Policy Manual; third party payer denial and appeal processes.

Responsibilities

• Maintain professional and technical knowledge by attending education workshops, reviewing professional publications, establishing personal networks, and participating in professional societies.
• Document patient care services (pertaining to denial management) by charting in the Cerner EMR.
• Maintain patient confidence and protect operations by keeping information confidential.
• Adhere to standard work and apply appropriate criteria to patient care denials.
• Implement standard work.
• Develop templates related to RAC/Medicaid/Commercial denial management.
• Effectively manage timely transfer of information between parties critical to the patient denial.
• Assume the leadership role in achieving outcomes and making the health system work for the patient.
• Maintain a cooperative relationship among health care teams/departments by communicating information, responding to requests, building rapport, and participating in team continuous quality improvement and problem-solving methods.
• Contribute to team effort by accomplishing related results as needed.
• Identify, coordinate, and manage plans for identifying and developing actions to deal with medical necessity-based denials.
• Monitor, identify, and report suspected or emerging trends related to payer denials.
• Serve as a resource to Director and CRM Staff relative to regulatory changes and processes related to utilization management and clinical resource issues.
• Facilitate appeals/grievances for retrospective appeals.
• Manage all facets of the appeal/grievance process, including medical record review for medical necessity, conferring with appropriate Medical Staff leadership, formulating correspondence, and maintaining accurate files.
• Review all referred inquiries and identified denials against InterQual® Level of Care guidelines and/or other relevant review standards, including the Medicare Benefit Policy Manual, for appropriateness.
• Coordinate with the revenue cycle team the appeal process through the various stages for Recovery Auditor Contractor (RAC) Medicare/Commercial Denials.
• Obtain all PA State Medicaid Authorizations.
• Submit retro authorizations, pay class change authorizations, 30-day readmission denials, and authorizations from administrative denials for all commercial payers not handled by the physician advisors.
• Refer to Physician Advisors for secondary review of cases not meeting medical necessity against InterQual Level of Care or any cases being denied from payers.
• If the appropriate level of care and services were provided: Speak with attending physician or specialist to have a complete and comprehensive understanding of the clinical course/medical necessity for hospital care.
• Construct an appeal letter that is clinically oriented, patient specific, objective and measurable to rebut denied days/services based on InterQual® Level of Care Criteria and other relevant, generally accepted community standards of care.
• Record action in EMR and document through the various stages of appeal as appropriate.
• If the appropriate level of care or services are in doubt: Speak with attending physician or specialist to have a complete and comprehensive understanding of the clinical course/medical necessity for hospital care.
• Refer to physician advisors for secondary review of cases not meeting medical necessity against InterQual® Level of Care.
• As appropriate, refer cases to CRM Committee for review and recommended action.
• Manage the denial process in compliance with the time frames prescribed by various payers.
• Follow up with appropriate communication to payers in a timely manner when there is no response or inadequate response to appeals.
• Respond to Patient Accounting, Revenue Cycle Team, Case Managers, and other customers in a prompt, professional, and friendly manner.
• Monitor compliance for Medical Necessity and Two Midnight Rule of the MFFS patient population.
• Regularly attend CRM Committee and report on denial statistics.
• Review 30-day readmissions when denied for continuation of care relatedness.
• Document and track all commercial payer denials in the Cerner EMR.
• Identify and facilitate education opportunities with CRM staff and other stakeholders to decrease denials and appeals and improve quality to patients served.
• If negative payor trends are identified, work with CRM Director and Revenue Cycle Team to facilitate focus meetings with appropriate payor representatives to isolate opportunities for improvement and identify clear action for reversing negative trends.
• Provide periodic education on the denial and appeal process.
• Educate staff of new CMS regulations.
• Ensure that denials and appeals are managed in accordance with payor specific guidelines.
• Regularly communicate updates and status reports to stakeholders (CRM Director, and CRM Committee).
• Effectively communicate with Case Managers, Utilization Review, Director of CRM, Revenue Cycle Team, physician advisors, and Patient Accounting as well as other members of the healthcare team in a timely and appropriate manner.
• Attend Department meetings as assigned.
• Perform other related duties as assigned.

Benefits

• Excela Health is an Equal Opportunity Employer. It is the policy of Excela Health to prohibit discrimination of any type and to afford equal employment opportunities to employees and applicants, without regard to race, color, religion, sex, national origin, age, marital status, non-job related disability, veteran status, or genetic information, or any other protected class. Excela Health will conform to the spirit as well as the letter of all applicable laws and regulations.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level