Denials and Appeals RN

Job Opportunity At Nebraska Methodist Health System

At Nebraska Methodist Health System, we focus on providing exceptional care to the communities we serve and people we employ. We call it The Meaning of Care a culture that has and will continue to set us apart. It's helping families grow by making each delivery special, conveying a difficult diagnosis with a compassionate touch, going above and beyond for a patient's needs, or giving a high five when a patient beats a disease or conquers a personal health challenge. We offer competitive pay, excellent benefits and a great work environment where all employees are valued! Most importantly, our employees are part of a team that makes a real difference in the communities we live and work in.

Job Summary

Location: Methodist Corporate Office
Address: 825 S 169th St. - Omaha, NE
Work Schedule: Mon - Fri, business hours
Responsible for overall management and communication of clinically-based appeals between Methodist Health System and payers.

Responsibilities

Essential Functions

• Promotes positive relations when interacting with physicians, visitors, families, customers and co-workers.
• Greets, smiles and makes eye contact. Introduces self by name.
• Volunteers to help co-workers and other employees.
• Responds quickly to patients and/or other peoples' needs.
• Knows and demonstrates customer complaint management process.

Responsible for overall management and communication of clinically-based appeals between Methodist Health System and payers.

• Reviews each case identified/referred for appeal
• Utilizes InterQual and/or Physician Advisor to determine the viability of the appeal.
• Manage the appeal including documentation and communication to appropriate payer.
• Monitor for response and evaluate findings and rationale on denial and appeal tracking software when received.
• Follow up with appropriate communication to payers when there is no response or questionable responses to appeals.

Performs Medicare, Medicaid and commercial payer reviews of patients in the acute care setting.

• Construct a letter of appeal arguing a clinically-oriented, objective and measurable rebuttal to denied days/services based on InterQual guidelines, payor guidelines, and/or Physician Advisor.
• Collaborate with Physician Advisor by delivering accurate clinical picture and to assure appropriate decision is made to appeal.
• Demonstrates knowledge of appeal process for Medicare, Medicaid and commercial payers.
• Construct letters for all levels of appeal and adhere to payer timelines to ensure timely appeal to include discussion level letters if applicable.
• Communicates all pertinent information regarding denials of payment and/or levels of care to the billing office.

Monitor, identify and report suspected or emerging trends related to payer denials.

• Demonstrates a working knowledge of regulations and provider contracts governing coverage of inpatient observation and outpatient services.

Conduct pre-emptive audits of high risk target areas and report findings, including the below items.

• Review number of short stay admissions that do not meet medical necessity for inpatient. Communicate with business office if re-billing is required.
• Review number of three day transfer to SNF that did not meet medical necessity.
• Review number of Code 44 required.
• Review number of Inpatient only procedures done as an outpatient.

Collaborates with Methodist Health System, its physicians and its affiliates through communication with payers regarding medical necessity and institutional process issues and to decrease appeals and denials.

• Serves as a role model to promote collaborative relationships.
• Makes sure communication will occur as soon as problems or concerns are identified recognizing that other members of the team will have valuable input into the case.
• Facilitates communication among the Denials team members by communicating effectively to solve problems at a personal and unit level.
• Collaborate with physicians providing pertinent clinical information in appeal letters to promote respected working relationship.
• Remains approachable and professional at all times in working with other health professionals, ancillary staff, patients and family.
• Remains calm in difficult situations and effectively diffuses crisis and refers to appropriate supervisory levels as needed.

Acts as a resource and provides education/training to physicians, physician office staff, nurses and coders in a variety of settings: One on one; Group presentations and Quick sessions.

• Provides periodic education sessions of trends related to payer denials.
• Recognizes payer source and understands the principles of reimbursement per payer.
• Works in partnership with physicians, care coordinators, and utilization management to ensure the medical record accurately reflects medical necessity.
• Promotes the education of all members of the Denials & Appeals team, physicians, office and hospital staff.
• Is able to educate and explain the rationale and benefits for improving documentation of medical necessity.
• Communicates issues/trends (positive/negative) to Supervisor and/or Physician Advisor.

Utilizes data bases from internal and external sources that will demonstrate the effectiveness of the Denials & Appeals process to promote documentation of medical necessity. Participation in the Performance Improvement process

• Participates in data collection for Denials & Appeals and assures that the data is reliable and valid measures will be obtained through the use of data analysis tools and excel files.
• Provides follow-up on data collection to track denials in progress, wins/partial wins/losses, and ensure no appeal cases exceed allowed periods of time for pursuit of appeal.
• Uses the data collected to identify opportunities for improvement in Denials & Appeals process.

Schedule

Mon - Fri, business hours

Job Description

Job Requirements

Education

• Bachelors of Science in Nursing required.

Experience

License/Certifications

• Registered Nurse (RN) with current state license is required.

Skills/Knowledge/Abilities

• Five years clinical experience in medical surgical nursing and/or ICU or case management with strong computer skills to include Word and Excel, use of laptops, and Internet.
• Past experience in an acute care setting as a Denials and Appeals RN preferred.
• Excellent communication skills; verbal, written and strong teaching skills, critical thinking skills and knowledge of healthcare delivery system.

Physical Requirements

Weight Demands

• Light Work - Exerting up to 20 pounds of force.

Physical Activity

• Not necessary for the position (0%):
  • Climbing
  • Crawling
  • Kneeling
• Occasionally Performed (1%-33%):
  • Balancing
  • Carrying
  • Crouching
  • Distinguish colors
  • Grasping
  • Lifting
  • Pulling/Pushing
  • Standing
  • Stooping/bending
  • Twisting
  • Walking
• Frequently Performed (34%-66%):
  • Fingering/Touching
  • Keyboarding/typing
  • Reaching
  • Repetitive Motions
  • Sitting
  • Speaking/talking
• Constantly Performed (67%-100%):
  • Hearing
  • Seeing/Visual

Job Hazards

Not Related:

• Chemical agents (Toxic, Corrosive, Flammable, Latex)
• Physical hazards (noise, temperature, lighting, wet floors, outdoors, sharps) (more than ordinary office environment)
• Equipment/Machinery/Tools
• Explosives (pressurized gas)
• Electrical Shock/Static
• Radiation Alpha, Beta and Gamma (particles such as X-ray, Cat Scan, Gamma Knife, etc)
• Rad