Denials & Appeals RN Administrator

Requirements

• Minimum 5 years or more related experience preferably in a healthcare case management and patient insurance/billing environment3-4 years supervisory experience preferred.
• Medical records coding experience.is desirable.
• KNOWLEDGE AND SKILLS:
• Work requires advanced interpersonal skills necessary to work with physicians, hospital directors and managers to affect changes in clinical and fiscal operations, policies and procedures; to provide guidance, communicate and interpret complex patient billing and compliance information.
• Compensation Range:

Benefits

Additional Information

POSITION SUMMARY: The RN Appeal Administrator will be responsible for the Pre-denial/ Denial and appeal process in addition to Utilization Review, to validate the patient's placement to be at the most appropriate level of care based on nationally accepted admission criteria. The Appeal/ UR Administrator uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient's expected length of stay. The Appeal/ UR Administrator secures authorization for the patient's clinical services through timely collaboration and communication with payers as required. The Appeal/ UR Administrator follows the UR process, in addition to the pre-denial and denial/appeal process as defined in the attached job description and in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review. The Denials and Appeals Administrator assesses, plans, coordinates, and evaluates initial and ongoing denials. He/She obtains information on all denials occurring as related to observation and inpatient stays. The Denials and Appeals Administrator researches and responds to denials in a timely fashion. He/She communicates with multiple members of the clinical team in clear concise language taking the lead in the resolution of the clinical denials. He/ she identifies trends and responds to the trends by recommending changes in practice and or documentation of the clinical providers to promote a reduction in the denials trends. The Denials and Appeals Administrator collects and trends the data for the return on investment as it relates to denials and reports that data to the Director Care management for review. The Denials and Appeals Administrator combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Collaborates with physicians, Case Managers, revenue cycle personnel and payers to appeal denials. Performs activities related to insuring a denial appeals process that includes monitoring for patterns and trends and maximizing reimbursement within regulatory requirements. Position: Denials & Appeals Administrator (RN) Department: Denials Access Schedule: 40 Hours Days JOB REQUIREMENTS EDUCATION: Requires Bachelor's Degree in Nursing or related field. Graduate degree preferred. CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED : Licensed to practice professional nursing as a registered nurse in the Commonwealth of Massachusetts.

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