Denial Management Nurse

The Denial Management Nurse is responsible for developing and implementing a centralized program to promote greater efficiency with completing, tracking, and reporting clinical denial reviews to determine appropriate appeal of patient accounts. This individual will combine clinical, business, and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and through the retrospective denial of payments for rendered services. Through continuous assessments, problem identification, and education, this individual facilitates the quality of health care delivery in the most cost effective and efficient manner. This individual has highly enveloped knowledge and skills in areas of Medical Necessity, Patient Status Determination, Government and Commercial payor requirements, and Denial Management and Avoidance. Responsibilities include supporting the Denial Avoidance Program by ensuring there is accurate and concurrent clinical analysis of all pre- and post- claims denials within the UW Health system. This individual also provides clinical guidance and participates in the Jackson Hospital & Clinic UM Committee, Denial Management Committee by responding to requests for clinical consultation related to medical necessity denials, writing appeal letters, and other Recovery Audit activities. This individual participates in the Jackson Hospital Utilization Management Committee by providing analysis of utilization- and medical necessity-related denials. The Denial Management Nurse is considered a clinical expert in Denial Management and Avoidance and ensures all denied claims are accurately worked from a clinical perspective, and appropriately appealed to secure maximum reimbursement and minimize organizational write-offs. The incumbent partners with other key stakeholders as appropriate to identify and implement opportunities for improvement in clinical denial avoidance and management by developing training, facilitating quality improvement initiatives, providing structure for additional orientation and competency development. This individual will report to the Director, Case Management and will collaborate closely with leadership and staff within and outside of the case management, utilization management & revenue cycle teams for the purpose of improving clinical, operational, and financial outcomes.

Minimum education: ASN Degree in Nursing or other relevant healthcare field. Bachelor’s or master’s degree in Nursing or other relevant healthcare field, preferred. Minimum work experience: Three (3) years’ experience working within case management, utilization management or Denial Management Experience with business letter writing, e.g., appeals, preferred. Must at least be Licensed as a Registered Nurse in the State of Alabama or possess a Compact State License. Certification in area of specialty or eligible for certification, preferred. Must have Exceptional oral/written communication skills; the ability to independently research issues and make effective recommendations using critical thinking skills; effective analytical ability to solve complex problems and issues; excellent customer service skills and ability to work with a diverse group of people; track record demonstrating ability to function independently and as a team member, and consistently deliver quality outcomes; excellent organizational skills and attention to detail. competent in MS Outlook, Word, Excel, and PowerPoint.