Denials Management RN

The Denials RN is responsible and accountable for receiving, processing and documenting all concurrent denials for assigned facilities.  The RN  has an integral role within the revenue cycle  by providing clinical expertise in the denials management process.

The Denials RN performs a root cause analysis of the concurrent denial, formulates and implements a plan for addressing the specific root cause for that denial, identifies gaps in processes that lead to concurrent denials, documents and communicates findings to management.  Recommends and provides education in collaboration with their manager.

The Denials RN follows a standardized approach to managing denials in order to achieve the organizational objectives of financial stewardship and patient advocacy through accurate billing.

Incumbents will use professional judgment, independent analysis and critical-thinking skills to apply clinical guidelines, policies, and payer knowledge to ensure the best possible financial outcome.

The Denials RN is accountable for demonstrating a strong commitment to promoting quality every day by  demonstrating our organizational values of: Compassion, Inclusion, Integrity, Excellence, and Collaboration.

1. Determines appropriate admit status  for concurrently denied hospital stays, using utilization management guidelines, medical necessity criteria, critical thinking skills,  and physician advisor review.
2. Identifies denial root cause for each individual concurrent denial.
3. Determines appropriate denial resolution strategy based on individual payer policies.
4. Implements strategies, such as RN reconsideration and peer to peer physician review. 
5. Escalates challenging cases and concerning payer trends to Leadership.
6. Documents findings and determinations in electronic medical record or denial software.
7. Collects denial metrics and data for the generation of facility and payer specific denial reports.
8. Oversees collection and utilization of operational and benchmarking data to identify gaps in process,  recommend and set targets for improvements; and recommends process improvements to leadership.
9. Collaborates with  various internal departments to gather critical information and  to share denial trends and gaps in process.
10. Performs Medicare short stay reviews and validation as assigned.
11. Develops, reviews, and recommends policies which support the direction of denial prevention activities.
12. Facilitates orientation and onboarding of new staff by acting as a preceptor of newly hired denial RNs.
13. Performs other duties as assigned by the manager.

Required:

• Minimumthree (3)yearsclinical experience as Registered Nurse (RN) required.
• RN license
• BLS required within 3 months of hiring if located within hospital
  
  

Preferred:

• Graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN)) or related healthcare field. 
• 5 years of RN experience preferred.
• Minimum Three (3) years utilization management experience preferred
• Denials management experience preferred.
• Care Management certification (CCM or ACM) preferred