Hybrid Denials Management Specialist, Registered Nurse (RN) License Required

at St. Luke's University Health Network

• Job title: Denials Management Specialist, Registered Nurse (RN) License Required
• Job type: Full Time
• Experience level: Junior, Mid level
• Salary: Not specified
• Degree requirement: Associate's Degree
• Location requirements: Hybrid, Allentown, United States

About the role

• Denials Management Specialist reviewing inpatient CMS and third party denials for medical necessity. Assisting billing staff and writing appeal letters in a committed healthcare environment.

Responsibilities

• Reviews inpatient CMS and third party denials for medical necessity and tracks outcomes regarding appeal process.
• Assists billing staff regarding outpatient denials for experimental, coding or other issues that may require record review.
• Provides billing with information needed to obtain payment of claims.
• Monitors retro denials to ensure resolution within required time frames and logging of action e.g. no appeal, appeal level and final decision with revenue impact.
• Provides feedback to Case Management that can help in preventing future denials and assists in maintaining good communication and process flow between the 2 departments.
• Responsible for writing appeal letters for Inpatient CMS and Commercial late pick-ups, medical necessity, and other requested denials as deemed clinically appropriate.
• Investigates managed care and commercial insurance rejections, denials for possible experimental services and coding issues, providing supplemental information to resolve claim.
• Identifies operational issues that contribute to denials and rejections.
• Works with departments and providers to implement corrective actions to minimize lost revenue due to denials and rejections.
• Assists in preparing reports regarding denials to include volumes, number of appeals, case resolution, and impact on revenue and trending.

Requirements

• Registered nurse with current license to practice in the state of Pennsylvania or seek Pennsylvania licensure through reciprocity.
• Graduate of an accredited professional nursing program.
• Minimum of 2-5 years of clinical nursing experience in an acute care hospital setting required.
• Prefer minimum of 2-5 years’ experience in case management and/or utilization management required.
• Prefer financial experience related to appeal processes with insurance providers.
• Demonstrated experience relating to all types of payers/providers.

Benefits

• St. Luke's is proud of the skills, experience and compassion of its employees.
• The employees of St. Luke's are our most valuable asset!
• Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.