Corporate Denials & Appeals RN
Location
Danbury, CT | United States
Job description
Nuvance Health has a network of convenient hospital and outpatient locations - Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center, and Vassar Brothers Medical Center in New York - plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care, and two urgent care offices. Non-acute care is offered through various affiliates, including the Thompson House for rehabilitation and skilled nursing services, and the Home Care organizations. For more information about Nuvance Health, visit
Title: Corporate Denials & Appeals RN Reports To: Corporate Supervisor/Director of Denial Management Department: Denial Management FLSA Status: Exempt Purpose: The Denials & Appeals RN is responsible for the systemwide retroactive medical necessity review of medical services provided. The position is integral in the revenue cycle on a system level and exists to partner Case Management and the System Business Office to overturn medical necessity clinical denials through the appeal process. The RN will review and respond to all payer (Medicare, and Medicaid, and commercial) medical necessity clinical denials. The RN will identify trends and responds to promote a reduction in the medical necessity denials. This position is key in revenue recovery and maximization of reimbursement.
Essential Responsibilities: - Reviews all medical and surgical medical necessity denials retrospectively.
- Determines the medical necessity for the appeals by reviewing medical records and utilizing clinical and regulatory guidelines.
- Discusses with Medical Director(s) or Physician Advisor (s) as needed to establish the appropriate level of care and/or plan for appeal.
- Ensures the submission of appeals to the payers within allotted timeframes to prevent fiscal penalties.
- Documents and logs appeal information on relevant tracking systems to provide accurate denial data.
- Conducts timely review of appealed cases to maximize the reimbursement.
- Maintains compliance with HIPAA regulations and accrediting requirements.
- Serves as a subject matter expert for appeal and a resource for the team members.
- Coordinates activities and strategies with the Case Management Department, Patient Access, Health Information Management, System Business Office, Managed Care, and Physician Advisors.
- Maintains and practices a professional image
Education and Experience Requirements: - Bachelor Degree in Nursing
- 3 years' experience in acute care Nursing
- 3 years' experience as a Utilization Review Nurse in a payer or acute care setting
- PREFER: Master's Degree in Nursing
- PREFER: At least 3 years of experience in revenue cycle management, preferably in a hospital provider environment
- PREFER: Experience in billing cycle language and managed care contract language
- PREFER: Experience with Medicare/Commercial appeals/denials
Minimum Knowledge, Skills and Abilities Requirements: - Must be knowledgeable about financial impacts of payer coverage associated to the organization and the patient
- Must be self-starter, highly motivated worker
- Ability to form positive, collaborative relationships with hospital staff, providers, patients and families
- Must have analytical abilities to assist in obtaining solutions to problems
- Must be able to work independently, manage stress, and prioritize work
- Must be able to manage multiple competing priorities and maintain calm demeanor in stressful environment
- Ability to interact with all members of the surgical team and administrative staff in a professional and courteous manner.
- Knowledge of InterQual and MCG as well as CMS Last Covered Day or LCD / Non - Covered Day or NCD documentation
License, Registration, or Certification Requirements: - Current NYS or CT Registered Nurse (RN).
Environmental Factors: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Potential environmental exposures include, but are not limited to: - Bio-hazardous Waste
- Blood Borne Pathogens. Job may require performance or tasks that involve potential for exposure to blood, body fluids, or tissues.
- Chemicals/Commercial Products
- Experiencing challenging conditions where a professional attitude will be required
- Exposure to Latex
- Fumes or Airborne Particles
- Interacting with a Diverse population
- Noise Level - Varies from Quiet to Very Loud
- Patient Care/Handling Duties
- Repetitive Motion
- Risk of Electrical Shock
Location: The Summit at Danbury, CT Work Type: Full-Time Standard Hours: 40.00 FTE: 1.000000 Work Schedule: Day 8 Work Shift: 8 AM - 4:30 PM Org Unit: 1133 Department: Care Coordination Exempt: Yes EOE, including disability/vets. We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this form or to participate in an interview, please contact Human Resources at 203-739-7330 (for reasonable accommodation requests only). Please provide all information requested to assure that you are considered for current or future opportunities.
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