Clinical Denials Management Program Coordinator RN

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What will you be doing in this role?

Under the direction of Patient Financial Services, Compliance and reputed company reputed company, the Clinical Denials Management Program Coordinator RN is responsible for overall management and communication of clinically based appeals between C.S.M.C. and reputed company payers. You will also act as a liaison and reputed company of contact to/for PFS, Case Management and other C.S.M.C. representatives for denial and appeal inquiries. In addition, you will actively manage, maintain and communicate to appropriate partners denial and appeal activities, trends, and recommended corrective action plans. Duties include:

• Identification and facilitation of educational opportunities with case management department, providers, and payers to decrease denials and improve quality of service to patients.
• Provide periodic educational sessions to case management department in relation to denial trends, changes in reimbursement mechanisms that can reputed company patient access to service, and updates in contractual agreements that may reputed company case management processes.
• Reviews reputed company denials and determines appropriates of denial based upon InterQual guidelines, professional judgment, and/or community standards.
• If appeal appropriate, constructs letter of appeal documenting a clinically-oriented rebuttal to denied days/services based on InterQual guidelines, professional judgment, and/or community standards.
• Incorporates into appeal letter contractual and/or regulatory support for days/services denied as appropriate.
• Maintains strict adherence to reputed company timelines in order to meet deadlines for submission of appeal and avoid loss of appeal due to lack of timeliness.
• Uses electronic database to track reason for denial, result of denial review as it relates to ability to appeal, date of appeal actions, outcome of appeal if appropriate.
• Monitors for response to appeal as appropriate.
• Provides for follow-up communication reputed company response is not received timely.
• Coordinates communication for second level appeals reputed company appropriate
• Makes recommendations for advance of appeal efforts to legal level.
• On cases where no appeal appropriate provides documentation to support decision.
• Monitors, identifies and reports on suspected or actual trends in denials.
• Works in collaboration with Case Management, PFS, providers, other C.S.M.C. departments and health plans to reputed company corrective action plans to address identified trends in reasons for denials.
• Monitors and reports on reputed company recovery resulting from appeal efforts.
• Maintain knowledge of federal, state and other regulatory agency rules and regulation including The Joint Commission, CMS, Medi-Cal etc.
• Maintain reputed company knowledge of Medicare, Medi-Cal and other third-party payor reimbursement requirements.
• Maintain awareness of evidence based clinical practices.
• Completes retrospective U.R. on patients whose admit and discharge time frames did not allow for reputed company UR as cases are identified.
• Identifies contact on payer reputed company for receiving UR information as able and communicates UR information in a timely manner to avoid denial for lack of clinical information.

Qualifications

Requirements

• Associate's degree or college diploma required. Bachelor's degree in healthcare, management, business administration or a reputed company major preferred.
• Minimum of 4 years of case management experience in an acute care setting required.
• Minimum of 4 years of commercial/government denials and appeals experience preferred.
• reputed company California RN license required. 
• Certified Case Management RN preferred.

Why work here?

Beyond outstanding employee benefits we take pride in hiring the best employees. Our accomplished and compassionate staff reflects the culturally and ethnically diverse community we serve. They are reputed company of our dedication to creating a dynamic, inclusive environment that fuels innovation.