Denials Manager RN

Overview

This position requires the full understanding and active participation in fulfilling the Mission of San Gabriel Valley Medical Center. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support San Gabriel Valley Medical Center's strategic plan and the goals and direction of the Performance Improvement Plan (PIP).

Medicare defines Medical necessity as "health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine."

Responsibilities

Specific Job Duties:

Ensures template for appeals includes reason for denial, diagnosis codes, MCG criteria used to support appeal, highlights of medical necessity supporting appeal, and only supporting documents necessary to support appeal are submitted with appeal template. Has knowledge of appeal deadlines and ensures appeals are submitted within this timeframe. Tracks responses to appeals, follows-up as appropriate. Working knowledge of levels of appeals, time lines, and contractual requirements related to appeals. Works with payers to resolve issues related to underpayments or increased denial trends. Ensures working knowledge of contracts to ensure appropriate reimbursement. Works closely with facility department directors such as Admitting, Case Management, Patient Accounting and CBO Directors to review, resolve and streamline all necessary aspects of the appeals process Establish appropriate tool for measuring Denial Tracking and Trending. Tracks and trends data, identifies opportunities for improvement, and establishes process improvement strategies as appropriate. Works closely with Case Managers regarding the Peer to Peer process for concurrent denials. Ensures they are completed within timeframes and logged. Creates a peer to peer report on weekly/monthly basis for presentation at denials meetings. May be asked to provide education and training to the Medical Staff, Nursing staff and or others related to denial prevention. Leads in RAC preparedness and assists facility in the time of RAC Audits. Participates in Continued Education in current laws that prevent unlawful denials, California Code of Regulations and HMO Compliance. Attends training and develops relevant knowledge and skills related to any identified gaps. Participates in all Corporate and Facility based Denials Meeting Participates in Utilization Management meetings as it relates to denials, as well as audits as assigned. Other responsibilities deems necessary regarding denials and denials prevention Performs other duties as assigned.

Qualifications

Minimum Qualifications

• Graduate of an accredited RN School of Nursing

• BSN preferred

• Four years recent acute care experience (critical care or emergency room setting preferred)

• Two years Utilization Management/Case Management experience

• Knowledge of the appeal process

• Working knowledge of MCG or Interqual Intensity of Service/Severity of Illness criteria.

• Working knowledge of Title XXII and Title XIX.

• Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, Shared Risk, and Managed Care.

• Ability to negotiate with the physicians, payers, and customers.

• Ability to track outcomes and report findings.

• Able to problem solve effectively.

• Ability to use clinical knowledge to identify potential quality issues.

• Must have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills.

• Must have strong clinical assessment and critical thinking skills necessary to provide utilization review appropriate to patients with complex medical needs.

• Must have the ability to work in a high volume caseload environment and deal effectively with rapidly changing priorities.

• Experienced in use of Excel/Google Sheets, Power Point/Google Slides, Word/Google Docs, email

Licenses/Certifications

Current California RN License

Current BLS Card