Denials Manager RN

Overview

The Denials Case Manager, RN appeals all denials using InterQual criteria and medical necessity.  Collaboratively works with all members of the revenue cycle team and all types of payers to resolve denials, maximize accurate and timely reimbursement, and perform reimbursement recovery and retention service.  Evaluates, tracks and trends denials, and implements denial prevention programs.  Works in collaboration with Case Managers, Physicians, Finance and multidisciplinary teams to ensure compliance with documentation and educates as needed.

This position requires the full understanding and active participation in fulfilling the Mission of San Gabriel Valley Medical Center. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support San Gabriel Valley Medical Center’s strategic plan and the goals and direction of the Performance Improvement Plan (PIP).

According to the American Case Management Association Standard of Practice, Case Management is expected to “advocate for the patient while balancing the responsibility of stewardship for their organization, and in general, the judicious management of resources.”

Medicare defines Medical necessity as “health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.”

Responsibilities

Specific Job Duties:

Qualifications

Minimum Qualifications

• Graduate of an accredited RN School of Nursing
• BSN preferred
• Four years recent acute care experience in a critical care setting (preferred)
• Two years Utilization Management/Case Management experience
• Working knowledge of MCG, Intensity of Service/Severity of Illness criteria.
• Working knowledge of Title XXII and Title XIX.
• Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, Shared Risk, and Managed Care.
• Ability to negotiate with the physicians, payers, and customers.
• Ability to track outcomes and report findings.
• Able to problem solve effectively.
• Ability to use clinical knowledge to identify potential quality issues.
• Provides proper notification of absence or tardiness within established departmental time frames.

Licenses/Certifications

Current California RN License

Current BLS Card