'RN-Clinical Appeal and Denials Coordinator Case Management Social Services'

Eisenhower Health
 Rancho Mirage, CA

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  • Job Objective: A brief overview of the position.
    • The RN-Clinical Appeals and Denials Coordinator reviews denied claims and processes appeals to the payer to recover payment for medical necessity, authorization and level of care denials. Reviews all assigned inpatient denials; obtains information as needed to file clinical appeals necessary to recover payer denial of reimbursement on inpatient, outpatient, or observation claims. Communicates clinical denial to appropriate departments and/or personnel for follow up and educational purpose.
  • Reports to
    • Director of Case Management
  • Supervises
    • N/A
  • Ages of Patients
    • All ages
  • Blood Borne Pathogens
    • Minimal/ No Potential
  • Qualifications
    • Education
      • Required: BSN
    • Licensure/Certification
      • Required: California Registered Nurse
      • Preferred: Certification in Case Management
    • Experience
      • Required: Four or more years of clinical experience
  • Essential Responsibilities
    • Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
    • Coordinates activities within the appeal process among the interdisciplinary team.
    • Utilizes strong communication skills within the interdisciplinary team to address information related cases.
    • Develops a strong working relationship with both the financial office and services, as well as the clinical providers in order to achieve positive outcomes.
    • Applies strong critical thinking skills to assess cases for strengths and weaknesses within the appeals spectrum.
    • Able to apply appropriate measured guidelines (Interqual), strong clinical knowledge, and outside resource information to cases to strengthen and support clinical appeals.
    • Applies strong writing and grammar skills to formulate professional appeal letters which clearly communicate both necessity and support for each appeal.
    • Collaborates with Clinical staff to encourage appropriate documentation of medical necessity, level of care, and treatment plan for each patient.
    • Educates clinicians, when appropriate, on appropriate documentation and level of care orders to limit denials.
    • Collaborates with Case management leadership to make determinations and recommendations for appeals and billing level of care.
    • Collaborates with financial services to facilitate accurate billing and claims reimbursement.
    • Works independently while meeting productivity standards to produce measurable positive outcomes.
    • Identifies, addresses, and works to resolve system problems impacting compliance.
    • Maintains Knowledge of current regulatory and compliance requirements.
    • Escalates cases as appropriate to leadership.
    • Keeps Denial log up to date.
    • Works closely with Payer Resource Coordinator to ensure all aspects of the appeal process are completed timely and submitted to payer.
    • Creates summary reports and audit results, and analyzes data to drive practice change and positively impact outcomes.
    • Reports physician related variances to the Utilization Management committee.
    • Adheres to all Eisenhower health policies, procedures, and standards, within budgetary specifications, including time management, productivity, and accuracy of practice.
    • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency, supports department -based goals which contributes to the success of the organization. And serves as a preceptor, mentor, and resource for less experienced staff.
    • Other Duties as assigned.