Clinical Denials Prevention & Appeals Specialist RN Per Diem

About the role

The Denial Prevention Nurse role is critical in preventing payment denials by providing timely and accurate clinical information to all payers, ensuring compliance with CMS requirements, guidelines, and standardized published criteria.

Responsibilities

• Review all inpatient admission and observation cases using InterQual, or Milliman Care Guidelines or CMS 2 Midnight Rule (depending on payer) within 12-24 hours of admission, seven days a week for assigned shifts.
• Complete an initial screening review within the first few hours of decision to admit from ED and communicate with appropriate Provider if initial status is to be re-considered.
• Identify incomplete clinical reviews in work queues and complete them within two hours whenever possible. Escalate if clinical information is not available by the time the lack of a review may result in a denial.
• Identify and complete clinical reviews required for submission to specific payers.
• Validate admission orders for all new admits/observations/outpatients daily.
• Ensure that the patient status order documented in the chart aligns with the MCG and/or InterQual criteria, or the CMS Two-Midnight Rule, to support the appropriate status and level of care.
• Prioritize review of all outpatient observation and outpatient bedded cases at least every 8 hours for conversion to inpatient status or discharge opportunities.
• Participate in daily Observation Huddles.
• Conduct concurrent reviews for all payers daily for the first three days of admission, then every 2-3 days, or more frequently if criteria are waning.
• Submit concurrent reviews to payers to ensure authorization of all days for per diem and percentage of charge reimbursement payers.
• If concurrent inpatient case does not meet medical necessity review criteria during the first level review, discuss with the attending MD to obtain additional clinical information and documentation to support inpatient level of care. If the case still does not meet, send to the Physician Advisor (PA) for a second level review.
• Forward cases that require secondary physician review to appropriate resource (e.g., Physician Advisor).
• Resolve any discrepancy at the time of review. If unable to resolve, escalate to the PA and Utilization Review (UR) Leadership.
• Cook with the care team in changing patient status, as needed.
• Document and proactively communicate relevant clinical information to payers for authorizations for treatments, procedures, and Length of Stay.
• Ensure completion and delivery of required patient notices (by onsite team member). These include but are not limited to: HINNs, Condition Code 44, MOON, Connecticut notice of conversion, etc.
• Track and trend all appeals and communicate on a daily/regular basis with the Denials Management team.
• Aids in informing Managed Care contracting team with necessary contractual language to protect organization financial position specific to inpatient medical necessity requirements.
• Employs creative solutions with team members and leadership to prevent denials.
• Performs other duties as assigned.

Requirements

• Bachelor’s Degree (BSN) is highly preferred. Minimum of Associate’s Degree in Nursing required when accompanied by strong demonstrated competencies and significant experience.
• Minimum of 5 years experience in acute care Nursing. Minimum of 2-3 years experience as Utilization Management Nurse in an acute care setting required, minimum of 4 years experience required for Associate’s Degreed individuals.
• Prefer: Master’s Degree in related field.
• Knowledge of regulatory requirements for CMS.
• Recognizes that education is the responsibility of the individual as well as the organization.
• Sets external knowledge on payers (such as free email services as Becker’s).
• Must have analytical abilities to assist in obtaining solutions to problems.
• Self-starter and highly motivated.
• Must be able to work independently in a fast-paced environment, manage workload and prioritize work.
• Must be able to manage multiple competing priorities and maintain calm professional demeanor during peak demand.
• Possess a high degree of prioritization skills.
• Exceptional interpersonal skills to effectively communicate with the physicians, payers, and other members of the interdisciplinary care team.
• Current working knowledge of utilization management, performance improvement and managed care reimbursement.

Skills

• Proficiency in Milliman and InterQual Guidelines.
• Current RN License in Connecticut and New York.
• InterQual/MCG proficiency testing completed (preferred); required within 1 year of hire.