Appeals & Denials Case Manager

Elliot Health System Bedford , NH 03110

Posted 3 weeks ago

##Job Summary POSITION SUMMARY Under the direct supervision of the Manager of Case Management, the Appeals and Denials Case Manager pursues, analyzes and remains up to date on data regarding all medical necessity denials. He/She collaborates with physicians, case managers, hospital billing office staff and payers to appeal denials.

The Appeals and Denials Case Manager insures a functional denial appeals process, including measuring denial and appeal activity, monitoring for patterns and trends, and reporting the outcomes of these activities as requested.# He/She facilitates all aspects of the denial/appeal process which include maintaining database, tracking and trending denials, and reporting process outcomes. KEY RESPONSIBILITIES Acting as a liaison for all levels of health insurance appeals for clinically sensitive cases. Reviewing and interpreting the level of benefit coverage for prescribed therapies.

Coordinating and managing the process for submission, intervention and resolution of appeals. Understanding and interpreting insurance plan language to support appeal. Researching denial by reviewing the denial letter or contacting the insurer as well as any other available resources.

Assuring timeliness and appropriateness of all appeals based on insurance or state/federal guidelines. Generating and mailing appeal letter and supportive documents. Coordinating and managing communications with providers and/or partner contacts regarding denials, appeals, and reviews.

Preparing appeal summaries and correspondence and documents information for tracking/trending data. EDUCATION/EXPERIENCE/LICENSURE Education: Graduate of an accredited school of nursing.

Nurses hired after May 2015 must have a Bachelor#s degree in nursing or higher nursing degree or commit to achieving the degree within a specified time. Master#s degree preferred. Experience: Minimum 5 years# experience in hospital admission appeals, case management, or clinical documentation improvement.

Licensure: New Hampshire Registered Nurse or Compact State Registered Nurse License. Technical Certification: Ability to obtain BCLS qualification during orientation period and maintain throughout duration of employment.

Professional Certification: CCM or ACM preferred. Software/ Hardware:

Ability to advance basic computer skills as the health system adds new systems or performs upgrades to existing systems. OTHER REQUIREMENTS Schedule: Work schedule may include 8-12 hours per day with weekend/holiday coverage based on departmental needs.

May rotate to weekends to meet total program needs. Personnel are expected to cover for absences by rotating, working extra shifts, or use of on-call as needed. Nursing personnel are assigned to one area upon employment, but may be required to assume assignments in other areas to meet patient needs. Other:

Job Summary

  • POSITION SUMMARY

  • Under the direct supervision of the Manager of Case Management, the Appeals and Denials Case Manager pursues, analyzes and remains up to date on data regarding all medical necessity denials. He/She collaborates with physicians, case managers, hospital billing office staff and payers to appeal denials.

    The Appeals and Denials Case Manager insures a functional denial appeals process, including measuring denial and appeal activity, monitoring for patterns and trends, and reporting the outcomes of these activities as requested. He/She facilitates all aspects of the denial/appeal process which include maintaining database, tracking and trending denials, and reporting process outcomes.

  • KEY RESPONSIBILITIES

  • Acting as a liaison for all levels of health insurance appeals for clinically sensitive cases.

  • Reviewing and interpreting the level of benefit coverage for prescribed therapies.

  • Coordinating and managing the process for submission, intervention and resolution of appeals.

  • Understanding and interpreting insurance plan language to support appeal.

  • Researching denial by reviewing the denial letter or contacting the insurer as well as any other available resources.

  • Assuring timeliness and appropriateness of all appeals based on insurance or state/federal guidelines.

  • Generating and mailing appeal letter and supportive documents.

  • Coordinating and managing communications with providers and/or partner contacts regarding denials, appeals, and reviews.

  • Preparing appeal summaries and correspondence and documents information for tracking/trending data.

  • EDUCATION/EXPERIENCE/LICENSURE

  • Education: Graduate of an accredited school of nursing.

    Nurses hired after May 2015 must have a Bachelor's degree in nursing or higher nursing degree or commit to achieving the degree within a specified time. Master's degree preferred.

  • Experience: Minimum 5 years' experience in hospital admission appeals, case management, or clinical documentation improvement.

  • Licensure: New Hampshire Registered Nurse or Compact State Registered Nurse License.

  • Technical Certification: Ability to obtain BCLS qualification during orientation period and maintain throughout duration of employment.

  • Professional Certification: CCM or ACM preferred.

  • Software/ Hardware:

    Ability to advance basic computer skills as the health system adds new systems or performs upgrades to existing systems.

  • OTHER REQUIREMENTS

  • Schedule: Work schedule may include 8-12 hours per day with weekend/holiday coverage based on departmental needs.

    May rotate to weekends to meet total program needs. Personnel are expected to cover for absences by rotating, working extra shifts, or use of on-call as needed. Nursing personnel are assigned to one area upon employment, but may be required to assume assignments in other areas to meet patient needs.

  • Other:

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Appeals & Denials Case Manager

Elliot Health System