The work involves performing professional nursing duties in the coordination of denials management at the Erie County Medical Center Corporation. The incumbent manages and coordinates activities related to the denial appeal process. Work is performed under the direct supervision of the Director of Care Management. Supervision is exercised over lower level nursing and clerical staff. Does related work as required.
TYPICAL WORK ACTIVITIES:
Coordinates the appeal process for third party payer denials;
Collaborates with other departments to identify and resolve reimbursement issues;
Completes charge verification for cost outliers and forwards to third party payers to realize full reimbursement for disputed charges;
Completes retrospective pre-certification as needed;
Provides feedback to involved parties to prevent further reimbursement issues;
Collaborates with Corporate Compliance staff to coordinate Recovery Audit Contractor (RAC) medical necessity denial activity;
Develops reports to identify reimbursement patterns/trends, provides insights regarding patterns/trends and distributes reports to involved departments as needed;
Maintains denial databases;
Completes reimbursement requests for excluded procedure/service for submission to Medicare/Medicaid including Alternate level of Care applications;
Coordinates completion of quality concern responses;
Identifies documentation deficiencies and facilitates correction;
Educates facility staff on prevention denials of payment including admission and continued stay criteria, contractual requirements of various third party payers, necessary components to formulate a successful appeal letter and physician-to-physician review process;
Gathers data for evaluation of utilization of resources;
Participates in departmental Performance Improvement activities, staff meetings and interdisciplinary term conferences.
FULL PERFORMANCE KNOWLEDGE, SKILLS, ABILITIES AND PERSONAL CHARACTERISTICS: Thorough knowledge of utilization and denial concepts and reimbursement methodology; good knowledge of hospital based denials management; good knowledge of utilization review; good knowledge of third party payer reimbursements/denials; good knowledge of hospital structure, organization and functions; ability to establish and maintain effective working relationships; ability to communicate effectively, both in writing and orally; ability to meet appeal deadlines; ability to identify pertinent information in medical records; skilled in the use of computer applications; analytical skills; organizational skills; tact; initiative; physically capable of performing the essential functions of the position with or without reasonable accommodation.
A) Graduation from a regionally accredited or New York State registered college or university with a Bachelor’s Degree in Nursing and three (3) years of professional registered nursing experience in a medical/surgical setting and three (3) years of utilization review experience, one (1) year of which included denials management; or:
B) Graduation from a regionally accredited or New York State registered college or university with an Associate’s Degree in Nursing and five (5) years of professional registered nursing experience in a medical/surgical setting and three (3) years of utilization review experience, one (1) year of which included denials management; or:
C) Graduation from a regionally accredited or New York State registered school of professional nursing and seven (7) years of professional registered nursing experience in a medical/surgical setting and three (3) years of utilization review experience, one (1) year of which included denials management.
Possession of a license and current registration to practice as a Professional Registered Nurse as issued by the New York State Department of Health at time of appointment; and:
Possession of a PRI (Patient Review Instrument) Certification at time of appointment.
Erie County Medical Center - 23 months ago