Responsibilities:

• Payer Denial Management Nurse: Supports the denial and appeal process within the Payer Denial Management department. Coordinates denial appeal follow-up and analyzes provided clinical documentation, criteria application, physician advisor input, completes review of the medical record and formulates the appeal letter. Participates in the application of medical necessity review and utilizes criteria tool (MCG and/or InterQual). Ensures compliance standards are met with required elements and provides feedback to the management team. Relays physician, nursing and care manager documentation improvement opportunities to assist with appeal defense process.
• RAC /Payer Audit Nurse: Supports denials, appeals, within the Payer Audit department. Conducts audit reviews to assure activities conform to regulatory requirements. Coordinates denial appeal follow-up; analyzes provided clinical documentation, criteria application outcome, physician advisor input, completes review of the medical record and formulates the appeal letter. Expert in the application of medical necessity review criteria tool (MCG and/or InterQual). Supports the development of performance improvement strategies in response to identified patterns and trends involving government payers.
• Charge Capture Nurse: Supports the Observation charge capture process for the enterprise. Works with a multi-disciplinary team to evaluate and improve the charge capture process. Reviews the medical record for Observation cases to ensure accurate and timely billing of observation hours and appropriate charges. Utilizes the application of medical necessity review criteria tool (MCG and/or InterQual). Works cooperatively to review, evaluate and improve the charge capture process to establish an enterprise uniform process. Supports development of performance improvement strategies in response to identified patterns and trends.
• Other duties as assigned.

Education:

• Bachelor of Science in Nursingor Bachelor's degree in a related field preferred.

Certifications:

• Licensed Registered Nurse (RN) in the state of Ohio, BSN preferred.
• Professional certification as a Case Manager preferred.
• Expertise with InterQual and Milliman disease management ideologies preferred.

Complexity of Work:

• Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
• Must be able to work in a stressful environment and take appropriate action.

Work Experience:

• Minimum 3-5 years Care Management or Utilization experience which would include acute med/surg,ICU, or ER experience required.
• Expertise with InterQual and Milliman disease management ideologies is preferred.
• In-depth familiarity with third party billing requirement and regulations, billing documentation requirements preferred.
• Understanding of CPT and HCPCS coding guidelines preferred.

Physical Requirements:

• Manual dexterity to operate office equipment.
• Requires extended periods of standing, walking, sitting and carrying up to 10 pounds.
• Normal or corrected vision and hearing to normal range.

Personal Protective Equipment:

• Follows standard precautions using personal protective equipment as required.