WaterburyRecruiter Since 2001
the smart solution for Waterbury jobs

Clinical Appeals Nurse

Company: Waterbury Hospital
Location: Waterbury
Posted on: June 6, 2021

Job Description:

SCOPE OF POSITION: Represents the hospital where claims were denied by either governmental contractors or commercial payers. Completes comprehensive reviews of clinical documentation to determine if an appeal is warranted. Writes compelling clinically relevant appeal letters for denials related to medical necessity, payor audits, readmissions and others with use of appropriate guidelines and references. Monitors for patterns and trends to maximize reimbursement within regulatory requirements. Collaborates with Physicians other departments, i.e., Accounts Payable, Health Information Management, Case Management, Billing, Contracting, Business Office, Coding and others as appropriate. Responsible for maintaining the denials database (Allscripts/ACM) and other administrative duties as required. # RESPONSIBILITIES: Coordinates the submission of appeals to third party payers within allotted timeframes to prevent fiscal penalties with Allscripts/ACM. Is the key contact person for all medical necessity, readmission and DRG denials and processes each denial following the established framework in coordination with Case management, Health Management Information/Medical Records and Patient Financial Services. Collaborates with the Case Manager and/or Physician Advisor to review the medical record to gather missing supportive documentation to strengthen the appeals process. Maintains dialogue with payers about disputed claims and maintains documentation of ongoing efforts for each disputed claim. Assists in the writing of draft appeal letters and prepares and edits the final documents prior to submission to the third party payer. Interfaces with Physicians, Patient Financial Services, Health Information Management/Medical Records and Coding to obtain necessary information as needed to respond to denials. Enters all denial activity into Allscripts/ACM on a daily basis as third party payer responses are received. Utilizes Physician Leadership to interface with physicians as needed. Jointly maintains with Finance within Allscripts/ACM and Revenue Cycle: Tracking of denials; The level in the appeals process for each denial; The financial impact of denial management outcomes; And successfully overturned decisions. Generates reports of denial activity as identified with analysis of data and significant trends to the Manager of Denials-East Region, Director of Case Management, Utilization Management Committee and Revenue Cycle Team. Investigates and researches medical necessity denials and identifies process improvements to prevent similar denials from occurring. Identifies issues and problems that may adversely affect quality patient care, appropriate utilization of Hospital resources or optimal reimbursement to the organization. Communicates denial/appeal practice trends to the Manager of Denials- East Region Assists in the orientation of new staff regarding the denial and appeals process. Maintains up to date information from payers and distributes changes to all staff and departments involved in the appeal/denial process. Performs other related duties as needed/assigned Will report locally to Director of Case Management for time reporting (PTO, etc.,) # # # # REQUIREMENTS: # CT RN License Minimum 5 years of broad clinical experience Graduate nursing program (Diploma/Associates) BSN preferred or actively working towards BSN Proficient in Clinical criteria Knowledge of current reimbursement codes and models:# Commercial, Managed Care, Medicare and Medicaid, Public Assistance, coordination of benefits Strong analytic, data management and computer skills. Excellent interpersonal communication and negotiation skills with physicians, payers, and ####### peers. Technical writing ability for appeal letters and reports. Analytical abilities to aggregate and report findings and to assit in obtaining solutions to problems. Must be able to work independently, prioritize work and meet timelines Must be flexible and able to manage multiple priorities. # REVISED DATE: 02/22/2021 # # # # # # # # # # # #

SCOPE OF POSITION:

Represents the hospital where claims were denied by either governmental contractors or commercial payers. Completes comprehensive reviews of clinical documentation to determine if an appeal is warranted. Writes compelling clinically relevant appeal letters for denials related to medical necessity, payor audits, readmissions and others with use of appropriate guidelines and references. Monitors for patterns and trends to maximize reimbursement within regulatory requirements. Collaborates with Physicians other departments, i.e., Accounts Payable, Health Information Management, Case Management, Billing, Contracting, Business Office, Coding and others as appropriate. Responsible for maintaining the denials database (Allscripts/ACM) and other administrative duties as required.

RESPONSIBILITIES:

  • Coordinates the submission of appeals to third party payers within allotted timeframes to prevent fiscal penalties with Allscripts/ACM.
  • Is the key contact person for all medical necessity, readmission and DRG denials and processes each denial following the established framework in coordination with Case management, Health Management Information/Medical Records and Patient Financial Services.
  • Collaborates with the Case Manager and/or Physician Advisor to review the medical record to gather missing supportive documentation to strengthen the appeals process.
  • Maintains dialogue with payers about disputed claims and maintains documentation of ongoing efforts for each disputed claim.
  • Assists in the writing of draft appeal letters and prepares and edits the final documents prior to submission to the third party payer.
  • Interfaces with Physicians, Patient Financial Services, Health Information Management/Medical Records and Coding to obtain necessary information as needed to respond to denials.
  • Enters all denial activity into Allscripts/ACM on a daily basis as third party payer responses are received.
  • Utilizes Physician Leadership to interface with physicians as needed.
  • Jointly maintains with Finance within Allscripts/ACM and Revenue Cycle:
  • Tracking of denials;
  • The level in the appeals process for each denial;
  • The financial impact of denial management outcomes;
  • And successfully overturned decisions.

  • Generates reports of denial activity as identified with analysis of data and significant trends to the Manager of Denials-East Region, Director of Case Management, Utilization Management Committee and Revenue Cycle Team.
  • Investigates and researches medical necessity denials and identifies process improvements to prevent similar denials from occurring.
  • Identifies issues and problems that may adversely affect quality patient care, appropriate utilization of Hospital resources or optimal reimbursement to the organization.
  • Communicates denial/appeal practice trends to the Manager of Denials- East Region
  • Assists in the orientation of new staff regarding the denial and appeals process.
  • Maintains up to date information from payers and distributes changes to all staff and departments involved in the appeal/denial process.
  • Performs other related duties as needed/assigned
  • Will report locally to Director of Case Management for time reporting (PTO, etc.,)

REQUIREMENTS:

  • CT RN License
  • Minimum 5 years of broad clinical experience
  • Graduate nursing program (Diploma/Associates) BSN preferred or actively working towards BSN
  • Proficient in Clinical criteria
  • Knowledge of current reimbursement codes and models: Commercial, Managed Care, Medicare and Medicaid, Public Assistance, coordination of benefits
  • Strong analytic, data management and computer skills.
  • Excellent interpersonal communication and negotiation skills with physicians, payers, and

peers.

  • Technical writing ability for appeal letters and reports.
  • Analytical abilities to aggregate and report findings and to assit in obtaining solutions to problems.
  • Must be able to work independently, prioritize work and meet timelines
  • Must be flexible and able to manage multiple priorities.

REVISED DATE: 02/22/2021

Keywords: Waterbury Hospital, Waterbury , Clinical Appeals Nurse, Other , Waterbury, Connecticut

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Log In or Create An Account

Get the latest Connecticut jobs by following @recnetCT on Twitter!

Waterbury RSS job feeds