**At this time, only registered nurses with prior Utilization Review or Appeals experience will be considered**
General Summary of Position
Responsible for coordinating and monitoring the denial management and appeals process. Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided. Collaborates with physicians, Utilization Review RN's, Case Managers, revenue cycle personnel and payers to appeal denials.
Primary Duties and Responsibilities
Completes appeal process for denied days for medical necessity that meets Interqual criteria, or appear to be clinically justified.Completes evaluation of all external denials for medical necessity received by the hospital and coordinates decision making regarding the feasibility of initiating an appeal for each external denial for medical necessity.Develops medical summaries of denied cases for review by hospital administration and for possible legal/Maryland Insurance Administrative (MIA) action, where indicated.Identifies and implements strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials.Identifies system delays in service to improve the provision of efficient and timely patient care. Identifies process issues related to the concurrent Case Management system, including appropriate resource utilization and identification of avoidable days.Maintains records of concurrent and retrospective denial activity in conjunction with Case Management support staff. Monitors and tracks denials and appeal results, and coordinates information with Patient Financial Services (PFS). Reports data to the Director and Operations Review Committee.Meets with attending physicians and Physician Advisor, as appropriate, to clarify or collect information in the process of development of appeal letters.Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required.Participates in the educational process for physicians and hospital staff to address issues that impact the number and type of denials. Serves as a resource to all staff in areas of utilization review/management.Utilizes and analyzes current medical/clinical information as well as medical record information to complete appeal letters.May interact with and assist third party payer reviewers to facilitate appropriate care and ensure payment of services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources.May utilize research methods to collect, tabulate, and analyze data in collaboration with the medical staff, and hospital performance improvement initiates. Implements strategies to correct or modify trends seen through data analysis and outcome monitoring.May serve as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, orientation and formal educational offerings.Assists in the orientation of new staff regarding the denials and appeals process.May manage the department in the Managers absence. Keeps Manager informed about issues related to staffing and problem areas. Keeps Manager informed about issues related to quality, risk, patient/family issues and concerns, allocation of resources and vendor/payer issues. Assists the Manager in monitoring performance issues. Contributes to the performance evaluation process by providing feedback to the Manager and assisting the creation of professional development plans for UR Coordinators.Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.
Minimum Qualifications
Education
- Associate's degree in Nursing required and
- Bachelor's degree in Nursing preferred
Experience
- 3-4 years 2 to 3 years clinical experience required and
- 3-4 years 2 to 3 years UR experience in health care setting preferred and
- 1-2 years 2 years background/experience in hospital audits preferred
Licenses and Certifications
- RN - Registered Nurse - State Licensure and/or Compact State Licensure RN license in the District of Columbia or the State of Maryland depending on work location Upon Hire required and
- Certification in Utilization review, case management and health care quality Upon Hire preferred and
- If MFM, maternal fetal medicine (MFM) coding and billing yearly seminars Upon Hire preferred
Knowledge, Skills, and Abilities
- Excellent verbal and written communication skills.
- Persuasive writing skills required.
- Working knowledge of Office Suite software applications preferred.
This position has a hiring range of $87,318 - $157,289
