DENIAL MANAGEMENT SPECIALIST

Job Title

Maintain professional and technical knowledge by attending education workshops, review professional publications, establish personal networks, and participate in professional societies.

Document patient care services (pertaining to denial management) by charting in the Cerner EMR.

Maintain patient confidence and protects operations by keeping information confidential.

Adheres to standard work, and applies appropriate criteria to patient care denials.

Implements standard work.

Responsible for developing templates related to RAC/Medicaid/Commercial denial management.

Effectively manages timely transfer of information between parties critical to the patient denial.

Assumes the leadership role in achieving outcomes and making the health system work for the patient.

Maintains a cooperative relationship among health care teams/departments by communicating information; responding to request; building rapport; participating in team continuous quality improvement and problem-solving methods.

Contributes to team effort by accomplishing related results as needed.

Denial & Appeal Management - Case Finding

In conjunction with the Director of CRM, the revenue cycle team, and physician advisors, helps identify, coordinate and manage plans for identifying and developing actions to deal with medical necessity-based denials.

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

Serves as a resource to Director and CRM Staff relative to regulatory changes and processes related to utilization management and clinical resource issues.

Denial & Appeal Management - Facilitates appeals/grievances for retrospective appeals

Accountable for all facets of the appeal/grievance process, including medical record review for medical necessity, conferring with appropriate Medical Staff leadership, formulating correspondence and maintaining accurate files. Reviews all referred inquiries and identified denials against InterQual Level of Care guidelines and /or other relevant review standards, including the Medicare Benefit Policy Manual, for appropriateness.

Responsible for coordinating with the revenue cycle team the appeal process through the various stages for Recovery Auditor Contractor (RAC) Medicare/Commercial Denials.

Responsible for obtaining all PA State Medicaid Authorizations.

Responsible for submitting retro authorizations, pay class change authorizations, 30-day readmission denials, and authorizations from administrative denials for all commercial payers not handled by the physician advisors.

Refers to Physician Advisors for secondary review of cases not meeting medical necessity against InterQual Level of Care.

If the appropriate level of care and services were provided: Speak with attending physician or specialist to have a complete and comprehensive understanding of the clinical course/medical necessity for hospital care. Construct an appeal letter that is clinically oriented, patient specific, objective and measurable to rebut denied days/services based on InterQual Level of Care Criteria and other relevant, generally accepted community standards of care. Record action in EMR and document through the various stages of appeal as appropriate.

If the appropriate level of care or services are in doubt: Speak with attending physician or specialist to have a complete and comprehensive understanding of the clinical course/medical necessity for hospital care. Refer to physician advisors for secondary review of cases not meeting medical necessity against InterQual Level of Care. As appropriate, refer cases to CRM Committee for review and recommended action.

Manage the denial process in compliance with the time frames prescribed by various payers.

Follow-up with appropriate communication to payers in a timely manner when there is no response or inadequate response to appeals.

Respond to Patient Accounting, Revenue Cycle Team, Case Managers, and other customers in a prompt, professional and friendly manner.

Monitor compliance for Medical Necessity and Two Midnight Rule of the MFFS patient population.

Regularly attends CRM Committee and reports on denial statistics.

Reviews 30-day readmissions when denied for continuation of care relatedness.

Responsible for documenting and tracking all commercial payer denials in the Cerner EMR.

Quality/Education/Communication

Identify and facilitate education opportunities with CRM staff and other stakeholders to decrease denials and appeals and improve quality to patients served.

If negative payor trends are identified, work with CRM Director and Revenue Cycle Team to facilitate focus meetings with appropriate payor representatives to isolate opportunities for improvement and identify clear action for reversing negative trends.

Provide periodic education on the denial and appeal process. Educate staff of new CMS regulations.

Ensure that denials and appeals are managed in accordance with payor specific guidelines.

Regularly communicate updates and status reports to stakeholders (CRM Director, and CRM Committee).

Effectively communicate with Case Managers, Utilization Review, Director of CRM, Revenue Cycle Team, physician advisors, and Patient Accounting as well as other members of the healthcare team in a timely and appropriate manner.

Attend Department meetings as assigned.

Other related duties as assigned.

Required Qualifications

Graduate of an accredited Nursing Program required.

Bachelor's Degree in Nursing.

Three (3) years clinical experience in healthcare/case management or Utilization Review experience.

Strong leadership ability, good organizational skills, independent and critical thinking skills, sound judgment, and knowledge of legal aspects and liability of nursing practice.

Strong ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience.

Functional Skills on PC and Related Software (Microsoft Office)

Knowledge of basic Office Equipment such as copier, fax machine, etc.

Proficiency in the use of Excel Spreadsheets, PowerPoint, and various software programs

Preferred Qualifications

Case Management Certification.

Recent case management/denial and appeal experience.

Masters Degree in Nursing or related healthcare field.

Knowledge of Payer/Insurance Benefits

Working knowledge of InterQual Level of Care Criteria and other relevant medical necessity screening tools, including the Medicare Benefit Policy Manual; third party payer denial and appeal processes.

License, Certification & Clearances

Current licensure to practice as a Registered Nurse in the State of Pennsylvania required.

Act 34-PA Criminal Record Check from the PA State Police System

Supervisory Responsibilities

This position has no direct supervisory responsibilities, but may serve as a coach and mentor for other positions in the department.

Position Type/Expected Hours of Work

Incumbent will be scheduled based on operational need (rotate shifts, standby, on-call, etc.).

Travel may be expected locally between Excela Health locations.

Excela Health is an Equal Opportunity Employer. It is the policy of Excela Health to prohibit discrimination of any type and to afford equal employment opportunities to employees and applicants, without regard to race, color, religion, sex, national origin, age, marital status, non-job related disability, veteran status, or genetic information, or any other protected class. Excela Health will conform to the spirit as well as the letter of all applicable laws and regulations.

Ability to perform the Essential Functions listed on the Physical Conditions and ability to perform the Essential Functions on the Working Condition chart below.

Work Environment

Effective March 2020 or during pandemic: goggles, face shield and mask are required according to CDC guidelines