About the position The position is responsible for coordinating denials with the Patient Business Service (PBS) center, ensuring compliant and complete clinical documentation, assisting with denials and related appeals, and identifying opportunities for revenue optimization. The role involves investigating denials, performing thorough chart reviews, providing education to clinical colleagues, and tracking identified trends to enhance revenue integrity.

Responsibilities

• Coordinate denial management processes for the Revenue Integrity department, focusing on retrospective follow-up and assisting in appeal processing.

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• Ensure tracking of denials and audits, identifying trends, and collaborating with Revenue Integrity colleagues and PBS on education and reporting.

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• Review and understand utilization review and coverage guidelines for multiple payers.

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• Identify solutions to issues affecting reimbursement related to denial prevention.

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• Serve as a resource contact, providing clinical information as requested by colleagues and payers.

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• Collaborate with the Revenue Integrity team on opportunities to improve front-end processes to support denial prevention.

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• Collaborate with intra-department and PBS teams on accurate documentation and reporting of key performance indicators.

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• Support the development of effective internal controls that promote adherence to applicable laws and program requirements.

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• Identify opportunities for process improvement and participate in implementation as needed.

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• Assist in the design and development of system enhancements while monitoring congruency with process goals and regulatory mandates.

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• Maintain a strong working relationship with the ministry Payer Strategy team to ensure proper identification and resolution of clinical denials.

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• Provide detailed understanding of resolving denials based on patient status and constructing warranted appeals for defined populations.

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• Interpret data, draw conclusions, and review findings with intra and inter-departmental teams.

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• Coordinate concurrent and retrospective audits of patient medical records and itemized bills as requested.

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• Keep abreast of denial trends and regulations concerning healthcare financing and payer relations.

Requirements

• Registered Nurse with a graduate degree from an accredited school of nursing and at least four years of nursing experience, including two years in utilization review/case management or comparable patient payment processing experience.

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• Current registration with the State Board of Nursing Examiners or a temporary permit to practice nursing in the assigned state.

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• Demonstrated knowledge of revenue cycle and denial management functions.

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• Knowledge of healthcare including government payers, federal and state regulations, healthcare financing, and managed care.

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• Experience in case management and utilization management.

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• Outpatient CDI experience preferred.

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• Knowledge of insurance and governmental programs, regulations, and billing processes is required.

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• Working knowledge of medical terminology and medical record coding experience is highly desirable.

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• Customer service background is required.

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• Working knowledge of Electronic Health Records (EHR) is preferred.

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• Ability to interact effectively with multidisciplinary teams, including physicians and other clinical professionals.

Nice-to-haves

• Bachelor's Degree preferred.

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• Experience in writing appeals and familiarity with third-party billing requirements and regulations.

Benefits

• Competitive hourly pay range of $35.6322 - $53.4483

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• Opportunities for professional development and continued education programs.

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