Appeals and Denials Registered Nurse in Syracuse, New York at Crouse Hospital

Responsible for denial prevention and resolution. Requires strong communication and presentation skills. Facilitates coordination between and among revenue cycle departments and clinical departments to prevent and appeal 3rd party denials. Partner with representatives and subject matter experts leveraging resources to cultivate standard work and process improvements across the organization. Develop plan to communicate, implement, drive and support operational and cultural changes. Create and deliver monthly/quarterly reports for the VP of Revenue Cycle Management, stakeholders and executive leadership.

Appeals & Denials Registered Nurse Position Responsibilities:

• Diligently reviews all documentation involved in post discharge or retrospective denials directly related to medical necessity, level of care, length of stay, readmissions, experimental and investigational, cost outlier and RAC denials.
• Proactively recommends and composes responses to various payers in accordance with the established timeframe.
• Proficiently submits appeals to the New York State Insurance Department or Dispute Resolution Arbitrating Agent when appropriate.
• Completes timely requests for Summary Plan Descriptions (SPD's) for self-funded plan appeals and follows the appeal process until resolution.
• Accurately enters and maintains patient information, denial or appeal notes/status in the department computer system.
• Regularly compiles and distributes reports detailing denial types and appeal determinations.
• Proactively analyzes reports to identify frequent denial issues and communicates with department leadership to suggest potential opportunities to prevent future denials.
• Routinely researches and proactively identifies current payer trends and practices.
• Consistently maintains confidentiality of all verbal and written communications and records.
• Establish standardized processes to assist in defendable appeals should claim issues occur.
• Work collaboratively with Patient Access, HIM, physician offices, ancillary departments, surgical registrar, etc. to identify root cause for problems that occur.
• Serve as a clinical consultant to the various areas.
• Education physician office practices on medical policy specific to authorizations / predetermination and document critical requirements.
• Assumes other duties as assigned by department leadership.

Appeals & Denials Registered Nurse Position Requirements:

• High school diploma or equivalent required.
• Currently licensed as a Registered Professional Nurse with New York State.
• Minimum of two (2) years clinical and administrative experience in an inpatient setting.
• Denials management in an acute care setting.
• Knowledge of medical billing regulations for major insurance carriers
• Knowledge of CPT, HCPCS and ICD-10 coding.
• Good working knowledge of InterQual criteria.