Description – Overview
Ideal candidate will have a BSN, current license to practice nursing, three to five years’ experience in clinical nursing, and one year of experience in utilization review.
The primary responsibility of the Denials Management Nurse is to utilize clinical expertise, insurance knowledge, business know-how, and high level communication to analyze the patient’s accounts, medical records and invoices to assist in the resolution for retrospective approval for denied services and possibly continued access needs.
Analyze invoices, medical records and accounts to prepare for appeal of insurance and/or third party payer denials. Utilize Explanation of Benefits, Hospital Patient account systems and Remittance Advises to verify denial and identify possible avenues of appeal.
Contact third party payers, insurance medical directors, case management, and utilization review to request reconsideration and/or appeal of claims requiring clinical intervention. Contact may be by phone, fax, written, and/or in person.
Coordinate appeal process and maintain appropriate follow-up on appealed claims and contact information.
Demonstrates thorough knowledge of third party payers’ EOB’ s (Explanation of Benefits) and ability to recognize areas for appeals and specific time limitations for appeals.
Demonstrates thorough understanding of applicable insurance websites, claim logic guidelines, and insurance guidelines for medical necessity review including Milliman and Interqual.
Maintains appropriate documentation via electronic databases
Reports regularly to the Operations Manager on clinical denial activities, including managing overturn rate data and continually evaluating activities at the ministry for improvement
Meets routinely or on an as needed basis with payers for “meet and confer” meetings as appeals progress through various levels of review, working with payer clinical resources to resolve cases.
Provides fact-based information on a regular basis on clinical denial performance with recommendations on process improvements to avoid denials in the future
Works with the Leadership to identify training and system gaps and develop strategies to address these gaps
Works as part of a team to develop dashboards and performance tools for ongoing reporting.
Required: Graduation from an accredited school of nursing.
Preferred: Bachelor of Science in Nursing (BSN)
Required: Current license to practice professional nursing.
Required: Five or more years experience in clinical nursing and one year of experience in utilization review. May substitute preferred BSN degree for two years of the five clinical nursing experience.
Preferred: Experience in utilization review with external payers within a Healthcare or Insurance setting. Case Management experience and Certification.
Computer skills (Microsoft Office, Outlook, Internet, typing skills) required; able to adapt to required software programs which support Utilization Management functions. Familiarity with health care documentation systems preferred.
Demonstrated creative problem-solving skills and a strong attention to detail and accuracy required
Possess knowledge of managed care insurance, governmental health programs, HMO’s and their impact on hospital and post hospital care reimbursement.
Must be able to work independently, anticipate and organize workflow, prioritize and follow through on responsibilities.
Superior organization and time management skills required; able to skillfully manage a high-volume caseload and to respond effectively to rapidly changing priorities
Shift: Day Shift