Care Manager Clinical Denials

About the role

The Care Manager Clinical Denials (CM-CD) is responsible for managing clinical audits and denials related to inpatient medical necessity and/or level of care, and coding. This role involves reviewing patient medical records and other pertinent information to determine why cases are denied and whether an appeal is necessary.

Responsibilities

• Reviews patient medical records and other pertinent patient information to determine why cases are denied and whether an appeal is required.
• Serves as a liaison between Case Management and physicians/providers.
• Performs departmental audits to validate the accuracy and appropriateness of charges being billed to the patient's account based on current charging policies and documentation of medical necessity.
• Conducts reviews to meet regulatory requirements (e.g., TDHSC/Medicare/Medicaid) and participates in preventable readmission initiatives.

Requirements

• Minimum Qualifications: Bachelor of Science in Nursing (Preferred), Diploma in Nursing, Registered Nurse: Licensed to practice Professional Nursing in the State of Texas.
• Certified Case Manager (CCM) OR Certified Clinical Documentation Specialist (CCDS) OR Accredited Case Manager-RN (ACR) specialty certification required within 2 years of employment.
• Five (5) years' experience including: three (3) years clinical role and two (2) years of Case Management, Utilization Management/Denials Management.
• Communication Skills: Above Average Verbal Communication (Heavy Public Contact), Writing/ Correspondence, Writing/ Reports.
• Proficiencies: MS Word, PC.

Work Experience

• Three (3) years clinical role.
• Two (2) years of Case Management, Utilization Management/Denials Management.

Knowledge/Skills/Abilities

• Analytical Abilities.
• Mathematical Knowledge.
• Medical Terminology Knowledge.
• Statistical Knowledge and Abilities.

Other Special Requirements

• Broad knowledge of healthcare and/or hospital business office practices and principles.
• Knowledge of third-party payer practices including precertification, filing deadlines, claims processing, coverage issues and referral requirements.
• Knowledge and understanding of state and federal rules and regulations related to Medicare and Medicaid, laws regarding confidentiality, compliance, release of information, probate and lien legislation, Fair Debt Collection practices, and insurance regulation.
• Effective organizational, planning, scheduling and project management abilities.
• Knowledge of general accounting principles.

Transportation

Not specified.