DENIAL RN

Position Summary
The Clinical Denials Appeal Nurse is responsible to review charts and write appeals for all clinical and administrative denials as provided by the Denials Team, Denial System and Cerner Utilization Management Module. Facilitates referrals to Physician Advisor and coordinates ongoing levels of medical necessity appeals. 

Primary Responsibilities
•    Ensure first level review is complete for all clinical denials
•    Facilitates referrals to Physician Advisor and coordinates ongoing levels of clinical appeals.
•    Coordinates the generation of appeal letters for all payor clinical denials (inpatient) and forwards these onto the Audit Team within the designated timeframe
•    Utilizes designated Denials Management tracking tool to communicate interventions
•    Review electronic clinical inpatient denials through the denial system
•    Participates in strategic initiatives to promote education to areas identified through denials
•    Functions as a resource to medical staff and hospital staff regarding regulatory and commercial payor requirements
•    Communicates concerns to other areas within the Hospital as appropriate (Performance Improvement and Medical Records Subcommittee) 
•    Maintain attendance (including tardiness) in accordance with departmental standards
•    Complete safety evaluation, JCAHO Education, TB Testing, Confidentiality, Information Systems usage and HIPAA/Corporate Compliance notification on an annual basis
•    Exhibit accepted level of Teamwork and RESPECT
•    Accept change as needed to meet departmental goals
•    Prepare or assist with other projects/duties as assigned

Desired Job Qualifications/Skill Sets
•    UM or Case Management experience is helpful. Coding experience will also be considered. 
•    Effective Communicator 
•    Able to interact with all levels of the hospital team, participating in action planning and educational activities
•    Well Organized
•    Working knowledge of case management, utilization management and various software’s systems utilized to support these processes.
•    Understanding of Hospital Revenue Cycle and how Coding, Documentation and Utilization impacts the revenue stream
•    Ability to work in a cross-functional environment 
•    Solid writing and computer skills (Excel, Word, PowerPoint, and Medipac). 
•    Graduate of approved School of Nursing, BSN preferred