Match score not available

Denials and Appeals Nurse- Full Time

extra holidays - extra parental leave
Remote: 
Full Remote
Contract: 
Experience: 
Senior (5-10 years)
Work from: 
Ohio (USA), United States

Offer summary

Qualifications:

Accredited BSN program completed, Licensed Registered Nurse in Ohio, 5 years acute care experience, 3-5 years utilization review nursing preferred, Experience in program management preferred.

Key responsabilities:

  • Develop and implement denials management program
  • Liaise with external payers to appeal claims
  • Coordinate patient records for pre-certification
  • Monitor key performance indicators for trends
  • Collaborate with Finance on denial prevention
Dayton Children's Hospital logo
Dayton Children's Hospital Large https://www.childrensdayton.org/
1001 - 5000 Employees
See more Dayton Children's Hospital offers

Job description

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

Required profile

Experience

Level of experience: Senior (5-10 years)
Spoken language(s):
English
Check out the description to know which languages are mandatory.

Other Skills

  • Coaching
  • Program Management
  • Collaboration
  • Teamwork
  • Customer Service
  • Mentorship

Nurse Related jobs