Remote Denial Coordinator-Clinical- RN (Registered Nurse)

This position requires a valid RN (Registered Nurse) license. This is a remote position with no direct patient care.

Essential Duties and Responsibilities: (List in order of importance or percentage of time spent on the particular responsibility. High to Low)

1. Working knowledge of all facets of insurance claim filing, requirements, and regulations. Review and perform all retrospective inpatient authorizations of days of stays. (16%)
2. Reviews, investigates and appeals all clinical level denials such as not medically necessary surgeries, inpatient stays or levels of care. Communicates results of audit/review results timely. (16%)
3. Audit Medical Records to retrieve clinical information requested from payers, governmental agencies, etc. Draft (in conjunction with a physician reviewer when indicated) appeal letters. Review and process all correspondence including approvals and denials/adjustments, demand letters and results from various levels of appeals. (16%)
4. Manages the operational aspect of other types of audits when requested. Maintain knowledge of SSC policies and procedures as it relates to department job functions. Ensures the appeal process flow for clinical staff and physicians meet appeal deadlines. Working with team to monitor, track, trend and coordinate denial resolution with facilities. (16%)
5. Communicates with all parties in a professional manner to alert specific problem issues. Ensure confidentiality of all patient accounts by following HIPAA guidelines. Adheres to compliance of CMS and other payer guidelines. Attend in-services, education sessions and department meetings as scheduled. (16%)
6. Displays an overall teamwork design, relationship building and coordination of activity. Practices the Standards of Service for the Shared Services Center. (10%)
7. Performs other duties as assigned by leadership. (10%)

 Qualifications:

Required Education: Bachelor of Science in Nursing (BSN), Two-year Associate Degree in Nursing (ADN) or Equivalent

 Required Experience:   2+ years of experience as a hospital-based nurse including clinical decision making knowledge

Preferred Experience: 3+ years of experience as a Case or Resource Manager including 1 year experience with medical necessity appeals at all levels

 Required License/Registration/Certification: RN  (must possess and maintain a current nursing license)

Reasoning Ability:

Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

Computer Skills:

To perform this job successfully, an individual should have knowledge of Word Processing software; Spreadsheet software and Database software.

Physical Demands:

In order to successfully perform this job, with or without a reasonable accommodation, the following are outlined below: 

 The Employee is required to read, review, prepare and analyze written data and figures, using a pc or similar and should possess visual acuity. 

The Employee may be required to occasionally climb, push, stand, walk, reach, grasp, kneel, stoop, and/or perform repetitive motions.           

The Employee is not substantially exposed to adverse environmental conditions and therefore job functions are typically performed under conditions such as those found in general office or administrative work.