This position reports to the Manager of Denials. The position will be responsible for completing clinical review of denied services, preparing clinical discussion and appeal letters to be sent to the payers. The Denial Management Nurse is considered a clinical expert in denial management and avoidance and ensures all denied claims are accurately worked from a clinical perspective and appropriately appealed to secure maximum reimbursement and minimize organizational write-offs.
Will collaborate closely with leadership and staff within and outside of the revenue cycle team for the purpose of improving clinical, operational, and financial outcomes. Job Detail : Develop the denials department and create workflows for in-house submission of denials. Ultimately, developing an in-house appeals department.
Determine root cause of denials Establish and manage relationships with AHS leaders, facilitate regular meetings to present, and review denials information Effectively manage the department’s workflow processes, follow productivity and quality standards, and ensure denied claims are submitted and followed up in a timely manner Understand explanation of benefits from payors in all areas of non-governmental insurance claims.
Analyze hospital claims data to identify contractual underpayments, denials, and billing errors. Make billing adjustments in system based on outcome of denial. Submit information to payors as necessary and follow up with payors on in-house submitted denials.
Manage assigned work queues (Revenue integrity and denials) Working with the department staff provide monthly denial reports to department manager, clinical departments, and case management. Able to work independently Education & Licensure Active NJ Registered Nurse (RN) license Bachelor of Science in Nursing (BSN) preferred Experience 3 - 5+ years of clinical experience (acute care preferred) Experience in: Utilization Review Case Management Clinical Documentation Improvement Medical Record Audits Denials/Appeals or Revenue Cycle
Full-Time