Denials & Appeals Administrator (RN)

Position Summary

The RN Appeal Administrator will be responsible for the Pre-denial/ Denial and appeal process in addition to Utilization Review, to validate the patient’s placement to be at the most appropriate level of care based on nationally accepted admission criteria. The Appeal/ UR Administrator uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay. The Appeal/ UR Administrator secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required.

Responsibilities

• Uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay.
• Secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required.
• Follows the UR process, in addition to the pre-denial and denial/appeal process as defined in the attached job description and in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review.
• Affords leadership in the resolution of clinical denials by assessing, planning, coordinating, and evaluating initial and ongoing denials.
• Communicates with multiple members of the clinical team in clear concise language to identify trends and respond to trends by recommending changes in practice and or documentation of the clinical providers to promote a reduction in the denials trends.
• Collects and trends the data for the return on investment as it relates to denials and reports that data to the Director Care management for review.
• Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused by concurrent and retrospective denial of payments for services provided.
• Collaborates with physicians, Case Managers, revenue cycle personnel and payers to appeal denials.
• Performs activities related to insuring a denial appeals process that includes monitoring for patterns and trends and maximizing reimbursement within regulatory requirements.

Requirements

• Requires Bachelor's Degree in Nursing or related field. Graduate degree preferred.
• Certificates, Licenses, Registrations Required: Licensed to practice professional nursing as a registered nurse in the Commonwealth of Massachusetts.
• Experience: Minimum 5 years or more related experience preferably in a healthcare case management and patient insurance/billing environment. 3-4 years supervisory experience preferred. Medical records coding experience is desirable.

Knowledge and Skills

• Comprehensive knowledge of clinical documentation and medical coding, and a working knowledge of patient financial billing regulations/requirements, reimbursement, managed care in order to understand the clinical and billing systems; review, interpret, and analyze clinical and patient financial reports and data; and plan, coordinate and prepare for corrections to accounts.
• Comprehensive understanding of medical records coding, patient billing policies and procedures and health insurance standards, as well as knowledge of supervisory/managerial techniques and principles in order to control hospital financial billing activities. Establish and implement financial policies and plans; assist with the install of new modules; provide training for staff at various levels.
• Advanced interpersonal skills necessary to work with physicians, hospital directors and managers to affect changes in clinical and fiscal operations, policies and procedures; to provide guidance, communicate and interpret complex patient billing and compliance information.