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Registered Nurse Clinical Denials & Appeals Reviewer

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Location: Buffalo, NY, United States

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Job Description

Salary: 36.19-54.29 USD

Facility: Administrative Regional Training Cntr

Shift: Shift 1

Status: Full Time FTE: 1.000000

Bargaining Unit: ACE Associates

Exempt from Overtime: Exempt: Yes

Work Schedule: Days

Hours:

M-F 8-4

Summary:

This position is accountable for carrying out and documenting the appeals process for denied claims denied due to reasons including, but not limited to clinical documentation/support for diagnostic related grouping (DRG) assignment, inpatient and outpatient medical necessity. The individual also works to maintain third-party payer relationships. This includes, but is not limited to, responding to inquiries, complaints, and other correspondence, and may include setting up arbitration between parties. Knowledge of state and federal laws relating to contracts and appeal processes is vital. Additional responsibilities include identification of root cause and process improvement opportunities to eliminate recurring clinical denials. The position acts as a liaison between front-end clinical areas and third party payers in scenarios related to denials and appeals. This position educates all members of the patient care team on an ongoing basis in relation to trends in denials, and clinical documentation. Responsible for working alongside coding, clinical documentation integrity, medical staff and revenue cycle on improving the overall quality and completeness of clinical documentation as related to DRG and level of care denial trends.

Responsibilities:

EDUCATION
  • Registered Nurse with a current New York State license
  • Bachelor of Science Nursing degree
  • Holds, or will obtain within one (1) year of hire, one of the following (or similar) credentials: Certified Documentation Specialist, Certified Coder (CPC/CCS), Certified Processional Medical Auditor (CPMA), Certified Case Manager (CCM) or any other certification approved by management

EXPERIENCE
  • Three (3) years of active nursing experience in acute care setting, coding, and/or case management
  • Three (3 ) years of experience monitoring, reviewing and appealing clinical denials or relevant experience preferred
  • Experience in working with third party payers strongly preferred

KNOWLEDGE, SKILL AND ABILITY
  • Excellent interpersonal skills working with the medical, nursing, case management, patient accounts, finance, managed care services and third party payors
  • Strong verbal and written communication and presentation skills
  • Demonstrates organizational skill, problem solving skills, facilitation, critical thinking and decision making
  • Extensive knowledge of third party payer guidelines (InterQual), accreditation and regulatory requirements
  • Knowledge of Manage Care Organization contracts/agreements
  • PC literate, spreadsheet work, analytical skills for reporting and interpretation

WORKING CONDITIONS
  • Occasional travel between CH facilities required
  • General office environment
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