Denials and Appeals Nurse

Facility

Work From Home - Ohio

Department

Utilization Review Team

Schedule

Full time

Hours

40

Job Details

Reporting to the Manager of Utilization Management and in partnership with the Physician Advisor provider team, Revenue Cycle leadership, Integrated Care Management leadership, and the Chief of Quality and Resource Management; supports the development and implementation of a comprehensive denials management program. This role functions as a hospital liaison with external third-party payers to appeal denied claims, research and coordinate completion of patient records required to retrospectively pre certify accounts, and appeal observation, inpatient, medical necessity, and DRG insurance denials. This role functions as an internal liaison for members of the clinical team, clinical and operational leadership in the promotion of best practice processes related to proactive denials management. This role monitors key performance indicators, identifies trends, and recommends areas for documentation and/or process improvement and promotes pro-active documentation compliance for reimbursement. Partners with the Finance and Revenue Cycle Team on appeal process and denials management and prevention. Collaborates with Data Analytics and Integrated Care Leadership to report data and trends for the purpose of education, denials prevention, denials management, and senior leadership reporting. Demonstrates dynamic ability to adapt to ongoing changes within the health insurance industry to effect and implement positive changes for the financial growth of Dayton Children’s Hospital. Recommends and oversees projects as appropriate. In addition to performing the essential functions listed below, may also be assigned other duties as required.

Department Specific Job Details

Education

• Completion of accredited BSN program required
  
  

Certifications

• Licensed Registered Nurse in Ohio required
• Current professional certification in evidence-based care guidelines in use at DCH, currently Milliman Care Guidelines preferred
  
  

Experience

• 5 years of acute care experience in a hospital required
• 3-5 years as progressive utilization review nurse and knowledge of payers and managed care contracts preferred
• Previous program management and development experience preferred
  
  

Skills

• Professional skills in a Healthcare setting required
• Strong teamwork and collaboration required
• Exceptional customer service and operating technology required
• Mentoring and Coaching Skills preferred
  
  

Education Requirements

Bachelors: Nursing (Required)

Certification/License Requirements

[Lic] RN: Registered Nurse (RN) - Ohio Board of Nursing