Job Description

Job Description

Work Shift

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advance technology. Capital Health is a five-time Magnet-Recognized health system for nursing excellence and is comprised of 2 hospitals. Capital Health Medical Group is made up of more than 250 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Position Overview

Manages and reviews clinical denial appeals to payers. Coordinates appeals for clinical denials to managed care/insurance companies and governmental agencies. Writes clinical appeals and audits patient medical and billing records to determine documentation and items billing are appropriate. Follows through to ensure that audit adjustments are made and corrective actions are taken to address identified billing, charging, and documentation issues. Prepares first, second, and third level appeals utilizing relevant clinical information and professional standards and guidelines.

Minimum Requirements

Education:Registered Nurse (RN). Bachelor’s Degree in Nursing (BSN) preferred.

Experience:Thorough understanding of clinical processes and knowledge of billing, coding and Milliman Care Guideline (MCG) criteria. Three years of experience in acute care utilization review preferred.

Other Credentials

Knowledge and Skills:Clinical knowledge to denial appeals process. Knowledge of regulatory and payer requirements for reimbursement and reasons for denials by auditors. Outstanding organization skills. Excellent verbal and written communication skills.

Special Training:Proficient in Microsoft Office. Ability to quickly gain comfort with other software programs needed to perform the essential functions listed below.

Mental, Behavioral and Emotional Abilities:Ability to manage multiple tasks simultaneously and ability to change priorities when necessary to meet deadlines. Demonstrates good judgment as well as attention to detail.

Usual Work Day:8 Hours

Reporting Relationships

Does this position formally supervise employees? No

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

Essential Functions

• Performs the clinical appeal process.
• Assists Revenue Cycle Denials Manager in identifying appropriate cases for appeal and determines what cases should be referred to outsource vendor.
• Applies clinical judgment to assess whether denial can be appealed.
• Prepares clinical appeals containing relevant and effective clinical documentation from medical record, supported by current industry clinical guidelines; use evidence-based medicine; include local and national medical management standards and clinical protocols.
• Uses data to evaluate effectiveness of appeals process.
• Creates and maintains relationships with colleagues and counterparts at payers as appropriate.
• Coordinates Recovery Audit Contractor (RAC) audits and direct appeal activity related to audit outcomes to appropriate resources.
• Documents and determines that the RAC audit criteria meets accurate medical necessity. Maintains full knowledge of the complexity of care to verify medical record chart.
• Maintains expert clinical knowledge required for proper verification of procedures performed for audits.
• Conducts all RAC related functions within the Patient Accounts Department. Coordinates audit responses and follow-up with HIM Representatives.
• Possesses and consistently develops the ability to understand medical policies for commercial carriers to determine the medical necessity for audits.
• Remains current with all governmental regulations and policies related to audits including RAC and others. Maintains working knowledge of governmental regulations for billing purposes when performing audits.
• Proposes contract language changes as a result of denial reviews and observations.
• Obtains a thorough understanding of managed care contracts as part of appeal process.
• Collaborates with physicians and leadership to enhance denial management and improve clinical documentation improvement efforts.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent Physical Demands Include

Occasional physical demands include:

Continuous Physical Demands Include

Lifting Floor to Waist 0 lbs. Lifting Waist Level and Above 0 lbs.

Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Color Discrimination, Accurate Depth Perception, Accurate Hearing

Anticipated Occupational Exposure Risks Include the following: N/A

Offers are contingent upon successful completion of our onboarding process and pre-employment physical. Capital Health will require all applicants (including contractors, travelers and consultants) to have an annual flu vaccine prior to start date, with the exception of individuals with medical and religious exemptions.

"Company will never ask candidates for social security numbers or date of birth during application phase. If you are asked for this information online, you may be a target for identity theft."

Job Tags

Contract work, For contractors, Local area, Shift work,

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