Specialist-Denial II RN

Job Summary

The Denial Mitigation-Appeal Specialist II RN serves in a key role of the BMHCC revenue cycle as demonstrated by the following: Performs reviews of clinical information and supporting documentation for acute care inpatient services and other account classes as assigned to determine appeal and or other actions such as: complete level of care downgrades for billing/clinical purposes, identifying further escalation options, participate in clinical meetings, reach out to payer contacts, communicate with physician clinics to obtain additional documentation to support appeal, collaborate with coding/billing for formulation of appeal with corrected claims and denial resolution in order to defend our revenue. The Denial Mitigation-Appeal Specialist II RN reviews the denial received from the payer, completes a thorough analysis of the patient’s clinical record and prepares a clinical timeline and summary of the account to determine next steps. In accordance with the guidelines, the Specialist compiles an appeal along with pertinent clinical and financial information to send along to healthcare insurance providers in response to post-claim denials received by BMHCC. Physician Advisor communication may be necessary to provide further clinical review from the physician perspective as needed in preparation of writing the appeal. The specialist follows the account throughout the entire appeal process and determines if escalation to manager or payer is next step to get a favorable outcome. Specialist may be required to defend appeal in a payer hearing or clinical meeting when indicated. The Denial Mitigation-Appeal Specialist II RN may have the opportunity to work remotely after 90 days when able to successfully meet productivity requirements and training goals as determined by the Manager/Director of the Denial Mitigation Department. The Denial Mitigation- Appeal Specialist II RN role reports to the manager of the Denial Mitigation Department and performs other duties as assigned.

Responsibilities

• Requires strong prioritization, organization, and both written and verbal communication skills.
• Requires extensive knowledge of payer guidelines and BMHCC contracts as it pertains to authorization and clinical denials as well as clinical audits.
• Requires a strong foundation and knowledge of payer portals and demonstrates the skill set in obtaining information from the payer for appeal submission.
• Must be able to meet quality and productivity standards as identified by the department.
• Reviews, assesses, and evaluates all communications/correspondences received in order to optimize reimbursement.
• Evaluates clinical information and supportive documentation prior to initial appeal action in order to optimize reimbursement and utilization of resources.
• Meticulously reviews extenuating circumstances and other outside variables from point of entry to discharge when responding to technical authorization denials.
• Compiles, analyzes, and distributes pertinent clinical and financial information to healthcare insurance providers in response to post-claim denials received by BMHCC.
• Prepares response to denials based on supporting clinical information in the medical record, applicable payer policies, NCDs, LCDs, and state and federal rules and regulations in order to enhance reimbursement and maximize customer satisfaction.
• Submits retro-authorization requests, reconsiderations, and appeals with careful regard to payer specific timeframes, contractual agreements, and preferred method of submission.
• Utilizes and builds knowledge base with regard to external appeals, hearings and escalation options outside the formal appeal process.
• Works closely with physician advisor for assistance with medically complex case appeals, hearings, or level of care issues.
• Reports denial trends to management in order to improve performance, and increase awareness of resources consumed with relation to reimbursement.
• Completes assigned goals and projects within designated timeframe.

Specifications

Experience

Minimum Required

• RN with 5 years clinical experience in acute healthcare setting and one or more of the following: 3-5 years insurance provider, auditing, or medical review experience performing activities related to denied claims such as obtaining authorizations, claims review, patient billing, appeal writing, auditing, and/or denial management; 3-5 years case management experience, or other related relevant experience.

Preferred/Desired

Education

Minimum Required

• Graduate of an accredited nursing program

Preferred/Desired

Training

Minimum Required

• Nursing, Case Management or Denial Management. Familiarity with electronic medical records and claims/practice management systems. Requires critical thinking and judgement and must demonstrates the ability to appropriately use standard criteria established by payers.

Preferred/Desired

Special Skills

Minimum Required

• Excellent interpersonal, communication, and writing skills. Advanced computer literacy skills. Strong analytical and problem solving skills with an ability to understand and troubleshoot interconnected data and denial processes. Excellent communication skills. Advanced computer literacy skills with the ability to type and key accurately.

Preferred/Desired

Licensure

Minimum Required

• RN

Preferred/Desired

• CCM;RN;CCS