A Clinical Denials Nurse is primarily responsible for utilizing clinical expertise, revenue cycle management & revenue integrity knowledge to analyze the patient’s accounts, medical records, and invoices to assist in the resolution for retrospective approval for denied services. This position will also perform clinical appeals and/or reconsideration of medical services that may have been denied, either in part, or in whole, during the initial claims determination phase in accordance with internal policy and procedures, as well as regulatory guidelines and timeframes. Denial of payment may be based on insufficient medical record documentation to support the level of care, billing/coding disputes, utilization review, determination that a treatment investigational/experimental, and/or that the treatment rendered is not Medically necessary. Additionally, this position will actively manage, maintain, and communicate denial / appeal activity to appropriate stakeholders and report suspected or emerging trends related to payer denials to the Leadership team.

Responsibilities include:

• Responsible for managing medical denials by conducting a comprehensive review of clinical documentation.
• Constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate module of InterQual® criteria (Acute, Procedures, etc.). If clinical review does not meet IQ criteria, other pertinent clinical algorithms and clinical judgement should be utilized.
• Prepares and documents appeals based on industry accepted criteria with the primary objective to overturn the denial and maximize reimbursement based upon services delivered and ensuring that the claim is paid/settled within a timely manner.
• Performs retrospective (post –discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.
• Demonstrates proficiency in use of medical necessity criteria sets, or other key factors or systems as evidenced by Inter-rater reliability studies and other QA audits.
• Review prospective, inpatient, and retrospective medical records of denied services for medical necessity
• Review of ED downgrades and coding denials for appeals for inpatient and outpatient services
• Ensures appeals and grievances are resolved in a timely manner
• Prepare clinical reviews and provides monitoring of cases involving medical decisions and quality of services and care
• Generate written correspondence to payors to achieve maximum overturn rate
• Provide input into corrective action plans for clinical and service events to improve decision-making or quality of care and services for internal and provider partner decisions
• Presents recommendations based on clinical review, criteria, and organizational policies
• Complies with HIPAA and other compliance requirements to protect patient confidentiality
• Contact guarantors regarding necessary steps to resolve an outstanding insurance balance while providing exemplary customer service
• Other duties as assigned

Qualifications:

• Current issued RN license required
• 3+ year of prior authorization/ denials experience
• Ability to conduct research regarding State/Federal appellate guidelines and applicable regulatory processes related to the appellate process.
• Knowledge of managed care and regulatory and payer requirements for reimbursement and reason(s) for denials by auditors.
• Medical Terminology, coding knowledge of HCPCS, CPT and ICD10.
• Ability to proficiently read, understand, and abstract information from handwritten and electronic patient medical records are essential prerequisites.
• Working knowledge of Microsoft Excel, Word and other Microsoft applications.
• Knowledge of third-party payer regulations related to utilization and quality review is also preferred.
• Experience and knowledge of managed care contracts, account receivables and revenue cycle functions.
• Working knowledge of provider billing guidelines, payer reimbursement policies, and related industry-based standards.
• Ability to maintain confidentiality of sensitive information
• Ability to manage multiple tasks with ease and efficiency

• Self-starter with a willingness to try new ideas • Ability to work independently and be result oriented

• Possesses excellent written, verbal and professional letter writing skills

Preferred Qualifications:

• Experience in case management, discharge planning, and/or utilization review is preferred.
• Knowledge of EPIC Patient Accounting system is a plus
• Knowledge of Meditech
• Coding certification for inpatient or outpatient services

Success Criteria:

People who are successful in this job will live and lead to these values:

• Will have respect for everyone
• Will act with Integrity
• Will deliver as a team
• Will do great work

Our Commitment to Diversity, Equity, and Inclusion:

Tegria Revenue Cycle Management Group is committed to creating an inclusive work environment for everyone. All Included! amplifies the notion of a Human-Centered workplace where the variety of experiences and information in the collective broadens the organization’s range for better decision making, creativity, and innovation. We are better because of our differences, as well as our similarities, not despite them.

We welcome and respect the variety of experiences, viewpoints, and cultural backgrounds that everyone brings to our workplace. Tegria RCM makes every effort to promote a workplace where leaders model inclusive behaviors and individuals feel respected, valued, and empowered, i.e., belong, and together promote and sustain an inclusive workplace.