Clinical Denial Appeal RN

At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.

Job Summary

• This position is to assess and utilize clinical and financial information. In partnership with patients, physicians, and other health care providers, this position will support utilization of resources and obtain correct reimbursement to assure appropriate reimbursement for the organization. Position reports to Director, Collections and supports the CBO related to denials or underpayments.  Identifies trends and disseminates all necessary information for appropriate action. Must be able to work flexible hours. Other related duties as assigned.

Essential Functions

• Assess clinical and financial information concurrently and retrospectively to evaluate medical necessity, level of care and coverage issues related to insurance plans
• Participates in telephone clinical review and multi-disciplinary referrals regarding patient care coverage issues
• Interface with hospital case managers, authorized payers and reviewers to resolve managed care issues, denial, reconsiderations and appeals
• Ability to collaborate with other departments and organizations
• Provides for educational needs, regarding managed care issues and interfaces with hospital staff, case managers, nurses and external customers/suppliers regarding concurrent coding issues.
• Works with the departments and HIM to train charge nurses and coders on how to improve coding to minimize over/undercharging by the departments
• Interacts with the plan representatives to resolve reasons for denial of payment
• Recognizes denial reasons (i.e. medical necessity, technical special/financial) and obtains the appropriate resource needed to resolve the account
• Provides representation at the hearing level as appropriate and coordinates the necessary representation (i.e., physician, case manager, nursing, etc.)
• Identifies trends in denials and refers to appropriate agencies as required (i.e., legal resources, state agencies, etc.) for appropriate action
• Proactively contributes to cost saving by identifying ways to improve clinical and/or other processes
• Makes efforts beyond assigned duties to facilitate continuous process improvement activities within department and institution
• Communicates effectively both verbally and in writing
• Complete all required documentation

Knowledge/Skills/Abilities/Expectations

• Approximate percentage of time required to travel: 0%
• Ability to communicate effectively
• Knowledge of the operations of patient billing; the UB -04, the Itemized Statement, coding information reported on claim and grievance procedures. Demonstrated knowledge of the State Medicaid structure and other insurance plans (i.e., commercial, Medicare, HMO/PPOs, etc.)

Education

• Degree in Nursing; associate or higher

Licenses/Certification

• None Required

Experience

• LPN or clinical denial experience > 3 yrs