Denials and Appeals Case Manager

Position Summary

The purpose of this position is to provide quality retrospective chart reviews for potential appeal of denied days for all payers including government and external denials. Staff track and trend denial activity and work with financial services to capture correct reimbursement for all these cases. Qualified candidates will demonstrate superior patient care and possess outstanding communication skills while adhering to our high standard of excellence.

Duties

• Provide Utilization Reviews for Short Stay and Observation
• Conduct retrospective review for potential appeal of all denied cases.
• Participates proactively and collaboratively to enhance reimbursements and reduce denials.
• Collects and maintains data to identify and analyze patterns, trends and solutions with reports on all denial activity.
• Documents avoidable delays and admissions.
• Promotes continuous quality improvement and efficient use of hospital resources.
• Collaborates with the interdisciplinary team on all complex cases.
• Maintains high level of customer service at all times.
• Review retrospective denials for managed care, Medicare and Medicaid.
• Present and educate staff on denials.

Qualifications

• RN Licensure NY State.
• Bachelor's Degree or enrolled.
• Five years’ experience in Acute Care Hospital.
• Good writing skills and computer efficient.
• Experience in CM, Quality or UM.
• Working knowledge of MCG and/or Interqual.
• Excellent communication and interpersonal skills.
• High level customer service.
• Creativity, flexibility, professional and courteous.
• Weekday and Weekend flexibility.
• Work independently.

Preferred

• Certification in CM, UM, Quality, MCG.
• Master’s Degree.
• Previous experience with appeal/denial writing.
• Proficient in Word, Excel and Access.
• Recent experience in tertiary care.
• Knowledge of regulatory requirements.
• Experience in psychiatry or pediatrics.
• Leadership skills, coding experience.
• Bilingual.

Special Notes

This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair. This function/position maybe designated as “essential.” This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities.