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.
Responsible for review and completion of denial/appeal requests. Stays current with Federal and State regulations regarding medical necessity for inpatient and observation hospitalizations.
Collaborate 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.
Stays current with the provider aspect of federal/state organization regulations related to inpatient and observation hospital level of care.
Uses evaluative and outcome data to improve ongoing care management services.
Education and Experience
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