Summary: Under the leadership of Patient Financial Services (PFS) management, the Clinical Appeals Nurse is responsible for assisting the Revenue Cycle Management team with identifying and preventing revenue leakage due to missing charges, Charge Master Descriptor issues, clinical denials, coding, contract management issues and etc. This position requires extensive knowledge of Federal, State, and payor regulations, reimbursement methodologies, and communication with third party payers to facilitate timely and accurate reimbursement. Perform root cause analysis and resolution of clinical denials.
The Clinical Appeals Nurse will be responsible for the following:
Reviews and completes denial/appeal requests.
Stays current with Federal and State regulations regarding medical necessity for inpatient and observation hospitalizations.
Collaborates with Case Managers, Utilization Review Medical Directors, Corporate Compliance, Admissions and Patient Financial Services on patient status for accuracy of billing.
Responsible for utilization review duties in collaboration with Case Managers.
Completes audits for appropriate utilization of resources, develops/implements action plans when appropriate.
Establishes goals and priorities consistent with mission and goals of Cook Children's Health Care System, as well as meets requirements of Joint Commission and other applicable federal, state and local regulatory and/or accrediting bodies.
Advocates for payment of services, collaborates with physicians and the UM Committee.
Collects and analyses denial data for submission to Department Leadership and the Utilization Management Committee.
Completes requested audit for medical necessity, develop/implements action plans appropriately. Reports delays to Department Leadership.
Conducts audits of potential high risk denial areas and implement action plans as appropriate.
Facilitates the completion of Case Management services and discharged medical record review as needed for medical necessity and appropriate patient status / service and plan of care.
Promotes the optimal allocation of health dollars through accurate, effective and timely appeals.
Uses evaluative and outcome data to improve ongoing care management services.
Associates in Nursing Required. Bachelors of Science in Nursing (BSN) preferred.
Texas Registered Nurse License Required.
Minimum two (2) years previous experience in managed care and denials management in a healthcare business office setting required, or minimum five (5) years previous experience in areas such as case management, utilization management, clinical pathways.
Extensive knowledge of healthcare third party reimbursement, variance and denial records.
Understanding of Managed Care contracts, denials and payor methodology.
Effective oral and written communication skills.
Prior experience with Epic Hospital Billing Resolute Preferred.
Licensure, Registration, and/or Certification:
Current Texas RN license Required
Internal Number: 40824
About Cook Children's Medical Center
Cook Children's Health Care System is a not-for-profit, nationally recognized pediatric health care organization comprised of eight entities – a Medical Center, Physician Network, Home Health company, Northeast Hospital, Pediatric Surgery Center, Health Plan, Health Services Inc., and Health Foundation.Cook Children's Medical Center Based in Fort Worth, Texas, the integrated system has more than 60 primary and specialty care offices throughout North Texas. Its service region includes Denton, Hood, Johnson, Parker, Tarrant and Wise counties, with an additional referral area encompassing nearly half the state.Cook Children's traces its roots back to 1918, but throughout its continual change and robust growth, it still embraces an inspiring promise – to improve the health of every child in its region through the prevention and treatment of illness, disease and injury. To live up to this promise, Cook Children's combines the art of caring with the use of leading technology and extraordinary collaboration to provide exceptional care for every child, every day.History – Cook Children's has a rich history of nearly a century of caring for children.Our Promise – Knowing that every child's ...life is sacred, it is the promise of Cook Children's to improve the health of every child in our region through the prevention and treatment of illness, disease and injury.Companies – Based in Fort Worth, Texas, Cook Children's is a not-for-profit organization that is comprised of eight nationally recognized companies.Community Health Outreach – Cook Children's Community Health Outreach works together with over 150 partner organizations to improve the safety and health of at-risk children through education, disease and injury prevention and support.Clinical Research – Cook Children's is home to a skilled team of research-minded physicians, nurses and health care professionals and administrators who drive our commitment to excellent clinical care and the search for medical advances.Public Relations – Cook Children's Public Relations works with national and local media outlets, produces Cook Children's publications, coordinates special events and helps develop key relationships within the community.Contractor & Vendor Information – Cook Children's contractors and vendors must ensure their employees are knowledgeable about working with our organization.Sponsorship guidelines – Cook Children's sponsors a select number of events that are strongly aligned with its promise to improve the health of every child in the region through the prevention and treatment of illness, disease and injury.