Denial Case Manager- HIM

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Department: Health Information Management
Shift/schedule: Full Time (40 hrs/wk)

GENERAL SUMMARY

Works under the supervision of the Manager of Utilization Review Case Management. The Denial Case Manager's primary job function is to review denials, both inpatient and outpatient to screen for appropriateness of peer to peer, reconsideration/re-review, appeal, rebilling, and/or adjustment. Works with both SOMC and outsourced appeal staff for referrals. Manages accounts that have been finalized to assist with closing out accounts. Responsible for maintaining tracking system of worked denials. Manages assigned worklists, pulled from electronic health record. Assists appeal writers with follow-up on appealed accounts, as assigned. Expected to attend, discuss, and present denial trends and issues during Denial Team meetings. Tracks and works all CMS less than two-midnight accounts to ensure compliance with regulations. Works with multi-disciplinary team to assure appropriate documentation. Supports each Strategic Value by providing exceptional service. Supports each Strategic Value by providing exceptional service. Performs other duties as assigned.

QUALIFICATIONS

Education:

• High School Diploma or successful completion of an equivalent High School Exam Required

• Graduate of an accredited school of nursing required

Licensure:

• Licensed to practice as an RN in Ohio required

Experience:

• Three years of progressively related experience preferred. Knowledge of advanced medical terminology and procedures, diagnosis, symptoms, disease processes treatments preferred. Case Management experience preferred.

JOB SPECIFIC DUTIES AND PERFORMANCE EXPECTATIONS

The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.


1. Performs denial screening processes for inpatient and outpatient denials for the organization, utilizing policies, contracts, regulations, MCG and InterQual criteria.

2. Sets up peer to peer reviews for providers and insurance companies; acts as a liaison for communication between the two.


3. Works with other SOMC departments on adjustments and rebilling, as needed.

4. Works with outsourced appeal companies.


5. Assists with closing out finalized appeals, with both internal and outsourced staff.


6. Manages tracking system of all denials worked.


7. Manages assigned worklists, pulled from the electronic health record.

8. Follows up on appealed accounts for appeal writers, as assigned.

9. Serves as a member of the denial team; attends scheduled meetings and is prepared to discuss and present on denial topics.


10. Manages all CMS two-midnight accounts; responsible for the tracking system and ensuring compliance with regulations.

11. Assists with documentation improvement, to decrease future denials.


12. Performs other duties as assigned.

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of the position in accordance with applicable law. A full job description is available upon request.

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Southern Ohio Medical Center is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, color, disability, ethnicity, gender identity, or expression, genetic information, military status, national origin, race, religion, sex, gender, sexual orientation, pregnancy, protected veteran status or any other basis under the law.

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