DENIAL MGMT COORD

The Denials Management Coordinator performs comprehensive review and management of insurance claims denials. Review, manage, and resolve denied claims related to authorizations, non-coverage, medical necessity, and others as assigned in a timely manner and possess a sense of urgency to turn around cases based on the rules and guidelines set by each payer. Work closely with the Revenue Cycle team. Serves as a daily liaison between case management, medical records, billing, registration, medical staff, payers, etc. relating to revenue recovery. The denial manager will seek guidance from the UM physician advisor(s) for medical necessity review and final approval of all correspondence written to the insurance companies as indicated. Coordinates and gathers all data necessary to send to denial sources in their pre-established limited time frame for peer-to-peer review or a written appeal letter. Sets up peer-to-peer reviews with the insurance company within the payer's set timeframe as indicated. For cases denied, review payer's letters about the claim denied, request a reconsideration if applicable, or form an appeal letter and defend the reasons why a patient met medical necessity to capture loss revenue. Must be knowledgeable of key payer's contractual agreement related to utilization review, denials, and their appeals process. Expected to be competent in writing appeal letters and meet appeal deadlines as set by statute and contractual agreements. Collaborates with physician(s), physician's office staff, registration staff, and Patient Finance Services to obtain the necessary information to support medical necessity to avoid and/or reverse denials. Works with business offices, patient finance services, and HIM departments to coordinate and ensure that the requirements are met for the Centers for Medicare and Medicaid Services, such as recovery audit contractors, Medicare's MAC, private insurances, and other governmental entities. Functions as a resource person for various departments involved in the utilization review process. Utilizes written criteria, standards, local and national coverage of determination, and norms, and then applies professional knowledge and clinical expertise/competence in evaluating the medical record and documents for appropriateness of level of care for patients' hospitalization (inpatient vs. observation). Supports the utilization review functions of the hospital by working closely with the UM physician advisors, who provide medical oversight. Attends utilization management committee meetings and reports on monthly denial and appeal activities, including trends and variances. Works closely with the physician advisor to provide on-going education and feedback to the medical staff as identified. Provides performance indicators and opportunities for improvement for the case management department. Acts as a liaison between the hospital and the payer source, i.e., Medicare, Medicaid, and private insurance companies. Tracks and trends all denials and appeals by DRG, physicians, and payers and provides proactive measures and strategies to avoid and decrease denials in the future. Perform other case management-related duties as designated by the director or team leader. Provides education to physicians/independent clinicians as needed in an attempt to avoid future denials.

Performance Expectations:

Demonstrate the aptitude to write appeals letters. Responds positively to change and able to handle multitask, challenging situations, and meet deadlines. Competent in utilizing levels of care criteria. Knowledgeable of third party payers' reimbursement methodology and contacts. Demonstrate the ability to track all denials and appeals and trends. Interacts with third party payers to reduce denials and trend all activities. Demonstrate practices of all establish patient safety and infection control intervention. Qualifications:

Education/Skills

Bachelor of Science Degree in Nursing from an accredited non-online university preferred.

Work Experience:

Three or more years' experience in Med-Surg is required. Three or more years relevant

experience in denial management, case management, or utilization management.

Working knowledge of utilization review and medical necessity screen criteria such as

InterQual Criteria and Millman guidelines is preferred.Working knowledge of coding,

clinical documentation improvement (CDI), and the revenue cycle process is preferred

Case management certification is preferred. Working knowledge of the prospective

payment system, third-party payers, accreditation agency standards, and other regulatory

requirements pertaining to utilization management and discharge planning is required.

Certification/Licensure-DUE UPON HIRE

Licensed RN able to practice within the State of MS

Mental Demands:

Exceptional oral and written skills are required to relate effectively to hospital staff,

physicians, physician office staff, and review agencies. Must be able to work

independently and have excellent organizational skills. The individual must have the

ability to type and be familiar with the rules of spelling, grammar, and punctuation.

Must have the ability to use a copier, telephone, and personal computer.