Utilization Review Denials Nurse

Description

Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve.

Summary:

Coordinates and leads all clinical denial processes and clinical audit activities. Collaborates with teammates involved in the denial process. Reviews all denial requests and leads the team in the strategy to appeal all clinical denials. Provides the clinical expertise to draft the first and second levels of an audit appeal. Works collaboratively with the Physician Advisors and subject matter experts for all audit and appeals work activities. Assists with documentation review to support the clinical documentation specialists and Patient Financial Services. Supports the Utilization Review Nurse team when necessary by applying established criteria to evaluate the appropriateness of admission, level of care, continued hospitalization and readiness for care transition; assures timely movement of patients throughout the continuum of care by conducting concurrent review and proactively resolving care, service, or transition of care delays/issues as necessary; in collaboration with the care team. This position provides third-party payers clinical information to assure reimbursement; and coordinating care with the treatment team, patient, family, and others. Communicates with physicians for appropriate documentation to support authorization of services.

Responsibilities:

1. Provides clinical expertise and organization to manage denials.

2. Stays up to date and proactive with all ongoing information, rules and regulations, Medicare and other payor regulations.

3. Reviews all denials and works collaboratively with the Physician Advisor and Case management Assistants.

4. Reviews and documents findings on all medical necessity and status denials.

5. Works closely with Patient Financial Services for issues related to reimbursement, denials, status, etc.

6. Evaluates clinical denials for validity and probability to overturn, proactively gathers required clinical documentation and formulates appropriate appeals. Coordinates with the Physician Advisor and Case management Assistants in order to establish appeals plan based on the type of denial.

7. Conducts case studies for those complex denials in order to plan appeal strategies and to educate peers.

8. Conducts pertinent discussions with auditors and follows appropriate appeals process within established timeframes.

9. Reviews and responds weekly to status issue queries from patient financial services, coders, Quality and other entities.

10. Responsible for summary reports of Lenoir UNC Health Care denials. Presents denials summary to UR committee bi-monthly and as needed.

11. Reports out at the weekly denial prevention meeting on status of at-risk dollars and appeal win rates.

12. Assists in documentation review in the clinical documentation specialist role when needed. Working with Clinicians and Coders to successfully implement documentation review for MS-DRG and AP-DRG payers on assigned Hospital Units.

13. Works closely with the Clinical Documentation Specialist Lead to develop provider and CDS education based on denial results.

Completes observation, admission, and continued stay reviews and related activities as needed to support UR Nurse team.

Other information:

• EDUCATION
• Graduate from an accredited school of nursing, BSN preferred.
• EXPERIENCE
• Minimum 3-5 years of applied clinical experience as a Registered Nurse required.
• 2 years utilization review, care management, or compliance experience preferred.
• Minimum 1 year clinical denials management preferred.
• LICENSURE/REGISTRATION/CERTIFICATION
• Licensed to practice as a Registered Nurse in the state of North Carolina.

Legal Employer: Lenoir Health

Entity: UNC Lenoir Health Care

Organization Unit: Care Management

Work Type: Full Time

Standard Hours Per Week: 40.00

Salary Range:$35.81 - $42.97per hour (Minimum to Midpoint )

Pay offers are determined by experience and internal equity

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: US:NC:Kinston

Exempt From Overtime: Exempt: No

Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.