Job Summary:

Decrease the monies lost to insurance companies due to denials. Generate appropriate appeals, both retrospective and concurrent, based on medical necessity criteria. 2. Identify opportunities to improve reimbursement. 3. Provide direction to the Case Management staff in relation to denials/appeals which includes training and monitoring of staff competency in performing insurance reviews.

Responsibilities:

The following is a summary of the essential functions of this job. The employee may perform other duties, both major and minor, that are not mentioned below; and specific functions may change from time to time.

• Review and identify medical necessity denials appropriate for appeal.
• Appeal appropriate medical denials to decrease/recover monies lost due to medical necessity denials.
• Research denials and identify medical necessity /contractual criteria for appeal.
• Knowledgeable of medical necessity criteria - McKesson Interqual Criteria and Milliman Care Guidelines.
• Knowledgeable of state and federal appeal processes.
• Maintain accurate database of denials, appeals and outcomes.
• Track denials and report on patterns, trends, and financial impact.
• Track and report level of care changes and delays in services that effect reimbursement.
• Work closely with Patient Accounting to Improve reimbursement.
• Establish and maintain a good working relationship with medical insurance vendors.
• Acts as a resource person for hospital staff and physicians that result in a reduction in denials.
• Provides information and Interpretation of third party payer guidelines.
• Confers with the attending physician to determine medical necessity for admission or continued stay, when necessary.
• Secures physician input for insurance appeals when necessary.
• Incorporates knowledge of clinical expertise, quality, insurance and finance into decision making and problem solving regarding denial management.
• Explores strategies to reduce Insurance denials, implements them and document the results.
• Maintains familiarity with the laws, regulations, and interpretation of utilization review and discharge planning. Remains up to date on changes in regulations, policies and procedures.
• Incorporates the highest standard of professional, clinical, legal, and ethical practice (i.e., maintains patient confidentiality).
• Collaborates with other departments within the outside the hospital as necessary (especially admitting, billing office, fiscal, managed care, insurance case managers, finance) and the screeners.
• Provides training and ongoing monitoring of case management staff including Interqual criteria training, monitors the effectiveness of staff application of criteria to insurance reviews, identifies problems and provides retraining as needed, Reports ongoing problems to the department director.
• Performs any other duties as assigned.

Experience:

Education:

RN, Graduate of an accredited school of Nursing

Experience:

Five (5) years of clinical nursing experience, two (2) years of Utilization Management or Appeal Management related experience

Training/License:

Current NYS RN license. Thorough knowledge of nursing theory, nursing practice and practice standards for Utilization Management as related to Medicare, Medicaid and HMO's. Working knowledge clinical criteria/guidelines such as McKesson Interqual Criteria and Milliman Care Guidelines.

Licenses / Certifications:

Current NYS license

Other:

Clinical competency; excellent verbal and written communications skills; strong organizational, problem solving skills; basic computer skills

About Us:

WMC Advanced Physician Services PC