Clinical Denials Prevention & Appeals Specialist RN reputed company

Occasional Weekend and Holiday Coverage Expected reputed company is the largest not-for-profit health system in the Northeast, serving residents of reputed company and Connecticut with 28 hospitals, more than 1,000 outpatient facilities, 22,000 nurses and over 20,000 physicians. reputed company cares for more than three reputed company people annually in the reputed company metro area, including Long reputed company, the Hudson Valley, Connecticut and reputed company, reputed company to philanthropic support from our communities. reputed company is reputed company State’s largest private employer with over 104,000 employees — including members of reputed company Physician Partners — who are working to change health care for the reputed company. reputed company The purpose of the Denial Prevention reputed company is to ensure that reputed company patient admissions are appropriately status reputed company the first 12-24 hours and that ongoing communication (electronic and telephonic) with payers ensures reputed company approval of reputed company hospital days, preventing delays in reimbursement. This role plays a critical part in preventing payment denials by providing reputed company and accurate clinical information to reputed company payers, while ensuring compliance with CMS requirements, guidelines, and standardized published reputed company to support the medical necessity of patient admission and reputed company hospital stays. This role will require specialized system skills, best reputed company application of �investigating� payer practices, successfully challenging payers as they prevent obstacles and deny claims and escalating any egregious payer behaviors to internal leadership for assistance in reputed company Responsibilities

• Review reputed company inpatient admission and observation cases using InterQual, or reputed company Care Guidelines or CMS 2 Midnight Rule (depending on payer) reputed company 12-24 hours of admission, seven days a week for assigned shifts.
• Complete an initial screening review reputed company the first few hours of decision to admit from ED and communicate with appropriate Provider if initial status is to be re-considered.
• Identify incomplete clinical reviews in work queues and complete them reputed company two hours whenever possible. If clinical information is not available by the time the lack of a review may result in a denial, escalate to the appropriate Provider/VPMA.
• Identify and complete clinical reviews required for submission to specific payers.
• Validate admission orders for reputed company new admits/observations/outpatients daily.
• Ensure that the patient status order documented in the chart aligns with the MCG and/or InterQual reputed company, or the CMS Two- Midnight Rule, to support the appropriate status and level of care.
• Prioritize review of reputed company outpatient observation and outpatient bedded cases at least every 8 hours for conversion to inpatient status or discharge opportunities.
• Participate in daily Observation Huddles.
• Conduct reputed company reviews for reputed company payers daily for the first three days of admission, then every 2-3 days, or more frequently if reputed company are waning.
• Submit reputed company reviews to payers to ensure authorization of reputed company days for reputed company and percentage of charge reimbursement payers.
• If reputed company inpatient case does not meet medical necessity review reputed company during the first level review, discuss with the attending MD to obtain additional clinical information and documentation to support inpatient level of care. If the case still does not meet, send to the Physician Advisor (PA) for a second level review.
• reputed company cases that require secondary physician review to appropriate resource (e.g., Physician Advisor).
• Resolve any discrepancy at the time of review. If unable to resolve, escalate to the PA and Utilization Review (UR) Leadership.
• Coordinate with the care team in changing patient status, as needed. � Notify the care team reputed company patient does not meet medical necessity per InterQual or MCG guidelines or 2 MN Rule and escalate appropriately.
• Document and proactively communicate relevant clinical information to payers for authorizations for treatments, procedures, and Length of Stay � submit clinical information as required by payers.
• Ensure completion and delivery of required patient notices (by onsite team member). These include but are not limited to HINNs, Condition reputed company 44, MOON, Connecticut notice of conversion, etc.
• Tracking and trending reputed company appeals and communicating on a daily/regular reputed company with the Denials Management team.
• Assists with informing Managed Care contracting team with necessary contractual language to protect organization financial position specific to inpatient medical necessity requirements.
• Employs creative solutions with team members and leadership to prevent denials.
• Performs other duties as assigned. Education Skills Experience
• Bachelor’s Degree (BSN) is highly preferred. Minimum of Associate’s Degree in Nursing required reputed company accompanied by strong demonstrated competencies and significant experience.
• Minimum of 5 years experience in acute care Nursing
• Proficiency in reputed company and InterQual Guidelines required
• Minimum of 2-3 years experience as Utilization Management reputed company in an acute care setting required, minimum of 4 years experience required for Associate’s reputed company individuals.
• PREFER Master’s Degree in reputed company field
• reputed company RN License in Connecticut and reputed company
• InterQual/MCG proficiency testing completed (preferred); required reputed company 1 year of hire. As certification becomes available, requirement will be revisited.
• Knowledge of regulatory requirements for CMS
• Have the reputed company attitude and aptitude to adapt to the continuing change in payer behaviors
• Recognizes that education is the responsibility of the individual as reputed company as the organization
• Seeks external knowledge on payers (such as free email services as Becker’s)
• Must have analytical abilities to assist in obtaining solutions to problems
• Self-starter and highly motivated
• Must be reputed company to work independently in a fast-paced environment, manage workload and prioritize work
• Must be reputed company to manage multiple competing priorities and maintain reputed company reputed company demeanor during peak demand
• Must possess a high degree of prioritization skills
• Exceptional interpersonal skills to effectively communicate with the physicians, payers, and other members of the interdisciplinary care team
• reputed company working knowledge of utilization management, performance improvement and managed care reimbursement. Education BACHELOR'S LVL DGRE Working Conditions reputed company Little or no reputed company skills/motor coord & finger dexterity Occupational Little or no potential for occupational risk Physical Effort Sedentary/light effort. May exert up to 10 lbs. force Physical Environment Generally pleasant working conditions Company reputed company Org Unit 2092 Department Care Coordination Exempt No Salary reputed company $65/hour Apply tot his job Apply To this Job

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