Position Summary
The Clinical Denial Management - RN participates in clinical review and development of well-constructed appeal arguments for reconsideration of medical services that may have been denied. Denial of payment may be based on insufficient clinical documentation to support the level of care, utilization review, determination that a treatment is investigational/experimental, and/or that the treatment rendered is not medically necessary.
Qualifications
EDUCATIONAL REQUIREMENTS
College Diploma in Nursing and Bachelor's Degree in Nursing within 3 years of start date.
Certification & Licensure Requirements
Registered Professional Nurse (RN) License Illinois upon hire and Certified Case Manager CCM through Commission for Case Manager Certification or Case Manager certification through American Nursing Association/ANCC within 2 years.
Experience Requirements
Minimum 3 years recent Case Management and/or clinical experience.
Skills And Knowledge
Requires excellent verbal and written communication, negotiation, and listening skills. Must be a self-starter who is adept at problem solving and possesses the skills necessary to plan, organize and achieve goals. Ability to multi task and adhere to work plans and timelines. Excellent attention to detail and follow-through. Demonstrate a clear commitment to high quality care and excellence.
Essential Functions
- The Clinical Denial Management - RN will review the case, and determine the potential for an appeal on a denied claim.
- Create quality appeal letters to achieve maximum overturn rate. The appeal letter will be written in an objective narrative form, utilizing appropriate formatting, appropriate English grammar, based on current evidenced based criteria, medical literature if applicable, healthcare statutes, and clinical judgment.
- Stays abreast of regulatory changes and payer policies.
- Utilizes evidenced based criteria and other resources to develop sound and well-supported appeal arguments.
- Performs duties in accordance with the ethical and legal compliance standards as set by Carle Health, and all regulatory agencies, including State and Federal.
- Maintains strictest confidentiality of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
- Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services.
- Review governmental contractors response letter in comparison to the medical records.
- Researches medical literature and evidence based medical publications to support the level of care provided.
- Reviews/audits medical necessity denials looking for patterns by services or by the physician.
- Works with leadership to improve clinical documentation, understand root causes, and to reduce denials.
- Works collaboratively with health information management coding staff, physicians and financial services to resolve payment denials and clinical documentation issues.
- Adept at working in a fast paced, collaborative environment with multi-disciplinary teams across the institution.
- Ensures quality and productivity standards are met or exceeded.
- Functions effectively within a team and participates and contributes constructively to produce results in a cooperative effort.
- Ensure workload is completed in an efficient and timely manner.
- Participates in projects as needed.
- Data analysis
- Write denial letters to payers.
- Communicate with insurance companies.
- Review chart and determine denial reason.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.
Effective September 20, 2021, the COVID 19 vaccine is required for all new Carle Health team members. Requests for medical or religious exemption will be permitted.