The role of the Denial Nurse is to promote the quality and cost effectiveness of medical care by applying clinical acumen and the appropriate application of policies and guidelines to denials. The Denial Nurse will review for appropriate care and setting and following guidelines/policies as it relates to denials. The Denial Nurse is responsible for processing denial letters for all affiliated groups, interpret denial language provided by the prior authorization nurse, coordinators, and medical directors, and place it into the appropriate templates while translating medical terminology into lay language and grading the reading level as appropriate. Denial nurse will work closely with the coordinators in the department for clinical guidance on denial cases.
Essential Duties and Responsibilities include the following:
Understand all aspects of the functionality of Access Express with respect to prior authorization and the denials.
Complete assigned tasks accurately and within specified time limits.
Maintain smooth working relations with co-workers and supervisors. Be a "Team Player".
Anticipate future events, set realistic goals, timetables, coordinate activities to ensure smooth work flow and time management.
Understand, promote and review with the principles of medical management to facilitate the right care at the right time in the right setting.
Understand all Regal Medical Management policies and procedures.
Communicate effectively and interact with the department managers, nurses, coordinators, regional medical directors and staff daily or as indicated regarding all denials processes.
Speak clearly, concisely and tactfully on all subjects related to Denials.
Maintain a working relationship with denials coordinators, the prior auth teams, pharmacy team, medical directors, and network management.
When necessary, act as liaison between the prior auth coordinators, prior auth nurses, and medical directors
Maintain regulatory Turnaround Time Standards per regulatory guidelines.
Document accurately and completely all necessary information in authorization notes.
Communicating with the prior auth teams and medical directors for those denials needing clarification with an accurate summary of the case and recommendation.
Demonstrates the ability to follow through with requests, sharing of critical information, and getting back to individuals in a timely manner.
Identifies denials department needs and report to management for improvement opportunities.