RN Case Manager in Cambridge, Massachusetts at Cambridge Health Alliance

Location: CHA Cambridge Hospital
Category: Registered Nurse
Department: Inpatient Case Management CH
Job Type: Full time
Union Name: MNA Cambridge

Work Schedule: Day
Shift Details: 7-3:30pm
Hours/Week: 36.00

Inpatient Case Management provides psychosocial assessments, evaluations, and referrals for adults, and/or families with psychiatric illness, substance abuse, and medical illness. Casework or therapy takes place in the hospital setting. Cross Training to all areas of Care Management

An Appeals and Denials Nurse works to ensure that hospitals receive appropriate reimbursement from insurance companies by reviewing and appealing denied medical claims. Responsibilities include:
- Review insurance claim denials and identify the reason for denial.
- Analyze medical records to determine if the care provided met medical necessity criteria.
- Prepare and submit appeal letters with supporting clinical documentation.
- Communicate with physicians, case managers, and insurance companies to gather information and resolve denials.
- Monitor appeal deadlines and track outcomes in work queue.
- Stay current with Medicare, Medicaid, commercial insurance policies, and regulatory guidelines.
- Identify denial trends and recommend process improvements to reduce future denials.

Qualifications/Experience:

• Education: Bachelor of Science in Nursing (BSN) degree preferred.
• Current or Conditional MA RN Licensure
• American Heart Association (AHA)BLS certification required
• Experience in utilization review, case management, and medical coding.
• Strong knowledge of medical terminology, documentation standards, and payer guidelines.
• 3-5 years of medical/surgical RN experience OR 3-5 years of other RN Case Management experience is required.

Please note that the final offer may vary within the listed Pay Range, based on a candidate's experience, skills, qualifications, and internal equity considerations.

In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity. We will not tolerate unlawful discrimination in the recruitment, hiring, termination, promotion, salary treatment or any other condition of employment or career development. Furthermore, we will not tolerate the use of discriminatory slurs, or other remarks, jokes or conduct, that in the judgment of CHA, encourage or permit an offensive or hostile work environment.