Overview

The Denials RN is responsible for managing all concurrent insurance denials for assigned facilities. This involves analyzing denials, developing and implementing corrective action plans, identifying process gaps, and educating staff to prevent future denials. The RN uses clinical expertise and critical thinking to ensure accurate billing and optimal financial outcomes, while upholding organizational values of compassion, inclusion, integrity, excellence, and collaboration.

Responsibilities

• Determines appropriate admit status for concurrently denied hospital stays, using utilization management guidelines, medical necessity criteria, critical thinking skills, and physician advisor review.

• Identifies denial root cause for each individual concurrent denial.

• Determines appropriate denial resolution strategy based on individual payer policies.

• Implements strategies, such as RN reconsideration and peer to peer physician review.

• Escalates challenging cases and concerning payer trends to Leadership.

• Documents findings and determinations in electronic medical record or denial software.

• Collects denial metrics and data for the generation of facility and payer specific denial reports.

• Oversees collection and utilization of operational and benchmarking data to identify gaps in process, recommend and set targets for improvements; and recommends process improvements to leadership.

• Collaborates with various internal departments to gather critical information and to share denial trends and gaps in process.

• Performs Medicare short stay reviews and validation as assigned.

• Develops, reviews, and recommends policies which support the direction of denial prevention activities.

• Facilitates orientation and onboarding of new staff by acting as a preceptor of newly hired denial RNs.

• Performs other duties as assigned by the manager.

Qualifications

Required:

• Minimumthree (3)yearsclinical experience as Registered Nurse (RN) required.

• RN license

• BLS required within 3 months of hiring if located within hospital

Preferred:

• Graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN)) or related healthcare field.

• 5 years of RN experience preferred.

• Minimum Three (3) years utilization management experience preferred

• Denials management experience preferred.

• Care Management certification (CCM or ACM) preferred

Pay Range

$30.39 - $44.06 /hour

We are an equal opportunity/affirmative action employer.