Clinical Denials Management Program Coordinator RN

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What will you be doing in this role?

Under the direction of Patient Financial Services, Compliance and Revenue Integrity, the Clinical Denials Management Program Coordinator RN is responsible for overall management and communication of clinically based appeals between C.S.M.C. and outside payers. You will also act as a liaison and point of contact to/for PFS, Case Management and other C.S.M.C. representatives for denial and appeal inquiries. In addition, you will actively manage, maintain and communicate to appropriate partners denial and appeal activities, trends, and recommended corrective action plans. Duties include:

• Identification and facilitation of educational opportunities with case management department, providers, and payers to decrease denials and improve quality of service to patients.
• Provide periodic educational sessions to case management department in relation to denial trends, changes in reimbursement mechanisms that can affect patient access to service, and updates in contractual agreements that may affect case management processes.
• Reviews all denials and determines appropriates of denial based upon InterQual guidelines, professional judgment, and/or community standards.
• If appeal appropriate, constructs letter of appeal documenting a clinically-oriented rebuttal to denied days/services based on InterQual guidelines, professional judgment, and/or community standards.
• Incorporates into appeal letter contractual and/or regulatory support for days/services denied as appropriate.
• Maintains strict adherence to all timelines in order to meet deadlines for submission of appeal and avoid loss of appeal due to lack of timeliness.
• Uses electronic database to track reason for denial, result of denial review as it relates to ability to appeal, date of appeal actions, outcome of appeal if appropriate.
• Monitors for response to appeal as appropriate.
• Provides for follow-up communication when response is not received timely.
• Coordinates communication for second level appeals when appropriate
• Makes recommendations for advance of appeal efforts to legal level.
• On cases where no appeal appropriate provides documentation to support decision.
• Monitors, identifies and reports on suspected or actual trends in denials.
• Works in collaboration with Case Management, PFS, providers, other C.S.M.C. departments and health plans to develop corrective action plans to address identified trends in reasons for denials.
• Monitors and reports on revenue recovery resulting from appeal efforts.
• Maintain knowledge of federal, state and other regulatory agency rules and regulation including The Joint Commission, CMS, Medi-Cal etc.
• Maintain current knowledge of Medicare, Medi-Cal and other third-party payor reimbursement requirements.
• Maintain awareness of evidence based clinical practices.
• Completes retrospective U.R. on patients whose admit and discharge time frames did not allow for concurrent UR as cases are identified.
• Identifies contact on payer side for receiving UR information as able and communicates UR information in a timely manner to avoid denial for lack of clinical information.

Qualifications