The Denials Prevention & Mitigation Administrator coordinates and monitors activities of the Appeals and Denials RNs, ensuring the appropriate reimbursement for the care delivered to patients. This position also holds the responsibility for being aware of ensuring regulatory compliance. The Denials Prevention & Mitigation Administrator demonstrates clinical nurse leadership, training/coaching abilities for new staff, support for current staff, project management skills, and the ability to communicate with payers in a professional manner. The Denials Prevention & Mitigation Administrator serves as a functional expert to other departments within the hospital system. The Appeals and Denials RN assists the Director to develop consistent processes and keeping the Director apprised of payer issues. The Denials Prevention & Mitigation Administrator oversees and facilitates medical necessity appeals as the result of concurrent and retrospective denials. Works closely with Business Office staff to ensure timely and accurate follow-up.

1. Responsible for the management of Appeals and Denials RN team, including but not limited to, operational oversight, hiring, training, and evaluation.
2. Compiles and reports denial trend data internally at Revenue Cycle meetings as requested by Director
3. Streamline and optimize appeal templates which will enhance productivity and maximize reimbursement.
4. Evaluates denials to ensure care is being delivered at the most appropriate level using recognized standards of care and guidelines. Demonstrates fiscal responsibility related to patient needs, resource utilization payer requirements and organizational goals.
5. Serves as the functional expert on compliance and regulatory requirements and current policies and procedures related to denial mitigation and appeals.
6. Attends, actively participates, and communicates with third party payers to ensure reimbursement for services provided. Oversees and facilitates medical necessity denials and appeals as the result of concurrent and retrospective denials.
7. Leads team and proactively meets with other departments and outside providers on process improvement
8. Review all documentation involved in post discharge or retrospective denials directly related to medical necessity, level of care, length of stay, readmissions, experimental and investigational treatments, cost outlier and RAC denials.
9. Proactively and professionally, with proper grammar and formatting, recommends and composes responses to various payers in accordance with established timeframes and enters information in the appropriate computer system.
10. Tracks and analyzes data related to payer and provide trends to identify frequent denial issues. Communicates with Revenue Cycle leadership to suggest potential opportunities to prevent future denials.
11. Review, revises and develops educational materials that reflect hospital and department policies and regulatory standards and presents to department staff as appropriate.
12. Identifies and seeks professional growth and development within personal area of specialization to promote and maintain optimal standards of practice.
13. Attends and participates in professional activities and educational offerings to enhance knowledge base within area of specialization.
14. Manages confidential information in accordance with Crouse Hospital policy and procedures.
15. Assumes other duties as assigned by department leadership.

MINIMUM EDUCATION/ CERTIFICATION/ LICENSURE

Required:

• • Currently licensed as a Registered Professional Nurse in New York State. Bachelor's degree required.

Required:

• Three (3) to Five (5) years acute care hospital experience. Utilization Management and/or Case Management experience required.
• Previous experience writing and managing appeals.
• Minimum 5 years Management and Leadership experience
• Experience in Case Management, Utilization management and writing appeals