The Denial Management Nurse is responsible for developing and implementing a centralized program to promote greater efficiency with completing, tracking and reporting clinical denial reviews to determine appropriate appeal of patient accounts. This individual combines clinical, business, and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for rendered services. Through continuous assessments, problem identification, and education, this individual facilitates the quality of health care delivery in the most cost effective and efficient manner. This individual has highly developed knowledge and skills in areas of Medical Necessity, Patient Status Determination, Government and Commercial payor requirements, and Denial Management and Avoidance. The Denial Management Nurse is considered a clinical expert in Denial Management and Avoidance and ensures all denied claims are accurately worked from a clinical perspective, and appropriately appealed to secure maximum reimbursement and minimize organizational write-offs. The incumbent partners with other key stakeholders as appropriate to identify and implement opportunities for improvement in clinical denial avoidance and management by developing training, facilitating quality improvement initiatives, providing structure for additional orientation and competency development. This individual will collaborate closely with leadership and staff within and outside of the revenue cycle team for the purpose of improving clinical, operational, and financial outcomes.
NAH reserves the right to make hiring decisions based on applicants' state of residence if outside the state of Arizona. NAH currently hires for remote positions in the following states:
Clinical Knowledge and Interpersonal Skills
• Completes clinical review of appropriate pre- and post-claim denials; prepares clinical discussion and appeal letters for appeal of appropriate patient accounts.
• Develops, reviews, and recommends policies which support the direction of the Denial Management program.
• Collaborates with Revenue Cycle, Physicians, Admissions, Coding, and Coordinated Care staff to answer clinical questions specific to denial management. Seeks consultation from appropriate disciplines/departments as required to expedite clinical review of potential denials.
• Responds to all internal and external requests for information, data, and/or education specific to clinical Denial Management.
Education to Clients
• Develops and administers clinical appeal guidelines; provides appeal direction using these guidelines to denial management staff. Provides clinical denial management consulting to physicians and other colleagues for appropriate patient accounts.
• Reviews and analyzes current audit information to educate colleagues both internal and external to the revenue cycle. Identifies, and initiates clinical quality improvement initiatives focused on improving both clinical quality indicators/outcomes and financial metrics.
Compliance/Safety
• Ensures compliance with all federal, state, and local regulations governing rendered patient services and reimbursement.
• Oversees collection and utilization of operational and benchmarking data to recommend and set targets for improvements; researches industry best practices and recommends process improvements to leadership.
• Evaluates reporting, statistics, and relevant surveys to assess departmental operational and fiscal performance. Participates in the review of program and workflow processes. Recommends and participates in the implementation of process improvements. Monitors and measures process changes.
• Performs other duties as assigned.
Education
Minimum Associate/BSN Degree in Nursing or other relevant healthcare field
Preferred Master’s Degree in Nursing or other relevant healthcare field
Certification & Licensures
Current unrestricted RN license within the state of Arizona- Required
Experience
Minimum Three (3) years’ experience working within case management, utilization management or denial management
Preferred Experience with business letter writing, e.g., appeals.
Healthcare is a rapidly changing environment and technology is integrated into almost all aspects of patient care. Computers and other electronic devices are utilized across the organization and throughout each department. Colleagues must have an understanding of computers, and competence in using computers and basic software programs.
Software Powered by iCIMS
www.icims.com