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SalaryWhy Work at Children's....
Here, it’s different. Come join us.
Children's Hospital Colorado has defined and delivered pediatric healthcare excellence for more than 100 years.
Here, the nation’s brightest nurses, physicians, scientists, researchers, therapists, and care providers are creating the future of child health. With an optimist’s outlook, a trailblazing spirit, and a celebrated history, we’re making new strides every day.
We’ve been Magnet-designated four times by the American Nurses Credentialing Center and are consistently recognized among the best of the best pediatric hospitals with #1 rankings in Colorado and the region by U.S. News & World Report.
As a national leader in pediatric care, we serve children and families from all over the nation. Our System of Care includes four pediatric hospitals, 11 specialty care centers, 1,300+ outreach clinics and more than 10,000 healthcare professionals representing the full spectrum of pediatric care specialties.
Here, we know it takes all of us, every role, to deliver the best possible care to each child and family we treat.
That’s why we build our teams toward a foundation of equity in access, advancement, and opportunity. We know teams of individuals with different identities and backgrounds can nurture creativity and innovation. We know we can see, treat, and heal children better when our team reflects the diversity of our patient population. We strive to attract and retain diverse talent because we know a truly inclusive and equitable workforce will help us one day realize our most basic calling: to heal every child who comes through our doors.
A career at Children's Colorado will challenge you, inspire you, and motivate you to make a difference in the life of a child. Here, it’s different.
Job Overview
The RN Clinical Denials & Appeals will be directly responsible for completing clinical appeals within the PFS Department. The RN will support the Patient Financial Services (PFS) team in reviewing Clinical Denials and review needs, coordinating across departments as needed to overturn denials, and help put preventative measures in place where able to avoid future denials. This role will support the PFS team in developing templates for the non-clinical Denials Specialists to use when submitting appeals and any other clinical review needs on the backend of Revenue Cycle.
Additional Information
Department Name: Revenue Cycle
Job Status: Full Time
Shift: M-F 7:30am-4:30pm
Qualifications
Education: Bachelor’s Degree in Nursing.
Experience:Minimum three (3) years of experience in clinical inpatient nursing, utilization management, or inpatient case management.
Licensure(s): Current Registered Nurse (RN) license.
Responsibilities
POPULATION SPECIFIC CARE
No direct patient care.
ESSENTIAL FUNCTIONS
An employee in this position may be called upon to do any or all of the following essential functions. These examples do not include all of the functions which the employee may be expected to perform
- Uses nationally recognized evidence-based utilization review criteria and reviews medical records to develop clinical appeal letters with supporting documentation.
- Assesses the appropriateness of clinical appeal requests by using evidence-based utilization review criteria, payer policies and Federal and State regulations.
- Conducts reviews of patient accounts when requested by payers, audit firms, patient and Revenue Cycle departments to determine the appropriateness of billed charges based on review of documentation in the medical record.
- Collaborates with Case Management, Physicians, Managed Care, Compliance, legal counsel, and Revenue Cycle teams to prepare appeals.
- Identifies trends and opportunities for denial prevention in collaboration with the appropriate multidisciplinary teams to improve denial management, documentation, and appeals process.
- May lead special projects, conducts meetings, conducts and analyzes regulatory research, performs audits and data analysis, and prepares documents or reports.
- Completes the resolution of claim audit/denied accounts by developing and submitting effective and formal appeals, reconsideration requests, and negotiation with payers that are supported by current industry clinical and coding policies and guidelines, CHCO’s charging practices and billing policies and procedures, and State/Federal laws and requirements.
- Partners with Managed Care to ensure that all payer Clinical Denials occurring outside of allowable contract terms are identified and escalated appropriately; develops and establishes opportunities to improve processes and outcomes.
- Coordinates and helps educate where appropriate Service Line Departments/Medical Director to obtain relevant clinical information needed to support the appeals and negotiation process as well as brings awareness when services being rendered are resulting in controllable denials.
- Provides expert guidance in areas of expertise, payer policies, denials handling and appeals.
- Demonstrates ability to problem solve and implement change in a positive, sensitive, and forward-thinking manner; develops goals and objectives and establish priorities.
- Demonstrates knowledge of CPT, ICD-10 codes, HCPCs and DRGs coding, understanding of payer rules and regulations, including Medicaid and Commercial Payers
- Works closely with PFS leadership and Revenue Cycle Leaders on denial prevention and appeals processes.
Other Information
Physical Requirements
PHYSICAL REQUIREMENTS
Vision - Near: clear vision at 20 inches or less
Weight Lifted/Force Exerted: up to 10 pounds/4.5 kilos, up to 1/3 of time
Hearing: able to clearly hear details
Sit: 2/3 or more of time
Talk: able to communicate verbally
Mental/Emotional: able to work in close proximity to others and/or in a distracting environment
Mental/Emotional: able to cope with stress effectively
Mental/Emotional: able to prioritize effectively
WORK ENVIRONMENT
Mental/Emotional: able to tolerate ambiguity
Mental/Emotional: able to prioritize effectively
Mental/Emotional: may be subject to many interruptions
Office Work Environment: Regular/frequent exposure
Bloodborne Pathogen Category 2: Occasional exposure to blood/body fluid
Equal Employment Opportunity
It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation. Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information.
Salary Information
Hourly Salary Range: $37.82 to $56.73
Benefits Information
Here, you matter. As a Children’s Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid time off, medical/dental/vision insurance, company provided life and disability insurance, paid parental leave, 403b employer match (retirement savings), a robust wellness program, and access to professional development tools, including an education benefit to help you advance your career.
As part of our Total Rewards package, Children's Colorado offers an annual employee bonus program that rewards eligible team members based on organizational performance. If organizational goals are met for the year, the bonus is paid out the following April.
Children’s Colorado delivers annual base pay increases to eligible team members based on their performance over the previous year.
