Denial and Appeals RN / Clinical Resource Management

Denial And Appeals Rn / Clinical Resource Management

Work where every moment matters. Every day, more than 40,000 Hartford HealthCare colleagues come to work with one thing in common: pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut's most comprehensive healthcare network. The creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole, rather than a single member organization. With the creation of our new umbrella organization we now have our own identity with a unique payroll, benefits, performance management system, service recognition programs and other common practices across the system.

Department Description: Integrated Care Partners (ICP) is a physician-led, clinically integrated health care network whose mission is to assist our members in providing the highest quality care at the most reasonable cost for our patients in the current, rapidly changing medical environment.

Position Summary: The Denial and Appeals Nurse is an integral part of the Care Management team. Their focus is on the management of the payer denial and appeals process. The Denial and Appeals Nurse is responsible for appealing inappropriate denials through all levels of the appeals process. The Denial and Appeals Nurse is able to work autonomously and swiftly, managing a high volume of complex cases across all HHC system hospitals.

Key Areas of Responsibilities:

• Follow standard work processes to manage denials and appeals
• Ensure activities are completed within regulatory and payer timeframes
• Develop and maintain collaborative relationships with internal and external stakeholders as needed to obtain additional information to properly formulate the clinical appeal and to resolve any issues that may arise during the appeals process
• Partner with the Medical Director and Physician Advisor staff to compose factually sound appeal letters for denial reconsiderations utilizing clinical documentation and contract language
• Maintain all documentation associated with the processing and handling of appeals to comply with regulatory standards and timeframes while maintaining an accurate, complete appeals record in the appropriate database
• Assist in analysis and documentation of root cause for denials
• Provide education to stakeholder groups on findings, analysis and mitigation strategies as needed
• Work with multi-disciplinary team to identify denial / appeal trends and supports development of performance improvement strategies in response to identified patterns

Other duties as assigned. Reports To: Manager, Clinical Resource Management

Other Locations: United States Regular Standard Hours Per Week : 40 Schedule : Full-time (40 hours) Shift Details : Monday through Friday 7a-330pm, no holidays and weekends