MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Current unencumbered licensure with the WV Board of Registered Professional Nurses, or appropriate state board where services will be provided, as a registered professional nurse OR Current multi-state licensure through the enhanced Nurse Licensure Compact (eNLC).
EXPERIENCE:
1. Five (5) years clinical experience in a hospital setting with Two (2) years of appeal writing, utilization review, or care management experience.
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor of Science in Nursing (BSN)
EXPERIENCE:
1. Prior case management experience preferred
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Completes clinical appeal writing for insurance denials.
2. Evaluates each patient medical record reviewing specific documents relating to patient treatment and billable charges, chronologically, identifying services billed versus services documented as rendered. Identifies acceptable versus unacceptable supportive information, based on JCAHO/AHA/Clinical Practice Standards.
3. Evaluates patient medical record versus the bill noting discrepancies in over-under and miss-billed items; correctly calculates the dollar total amounts for each discrepancy and submits necessary documents for adjustments
4. Negotiates with external auditors regarding billing issues as needed to reach agreement on disputed items; provides appropriate supportive documentation for questioned charges.
5. Completes and submits audits documentation in a timely fashion and legible manner. Completes work independently with minimum supervision.
6. Communicates regularly with clinical and administrative personnel to obtain further supportive documentation for billed services beyond what is found in the medical record.
7. Maintains current clinical knowledge through reading, attendance at seminars, clinical practice and informal sessions with other departments.
8. Provides timely information regarding bill defense problems to manager, and offers recommendations to eliminate the unnecessary loss of revenue.
9. Applies the medical necessity process to auditing to effectively maximize the hospital’s position in negotiation.
10. Participates in departmental projects and educational opportunities to enhance effectiveness of the audit unit. Coordinates and presents education to various groups within the hospital directed at identified problems.
11. Develops appropriate learning tools and objectives for presentations. Shares knowledge with others in a clear, concise and timely manner.
12. Coordinates all administrative activities with regard to denial management including: Collects all denial correspondence. Updates the denial database regularly to accurately reflect all denials received. Coordinates appeals process with Case Management, Patient Access, providers on appropriate accounts.
13. Aggressively appeals denials with payers to obtain maximum recovery of revenues.
14. Develops and/or coordinates training sessions ongoing for revenue cycle staff, clinical staff, etc. to maintain current practices with regard to payer denial activity.
15. Completes analysis and process improvement initiatives related to denials with clinical leaders in organization.
16. Prepares and distributes clinical denial reports as needed for various leaders and stake holders.
17. Assists with preparing and coordinating follow up activities to resolve organizational difficulties with regard to denials.
19. Identifies payer trends with regard to denials and communicates outcomes appropriately.
20. Attends all denial related meetings, as appropriate, to stay up to date on current organizational activities with regard to denials. Attends training sessions, internal and/or externally, and researches the latest best practice trends in handling denials.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
SKILLS AND ABILITIES:
1. Strong letter writing skills.
2. Diverse clinical knowledge.
3. Effective communication skills.
Additional Job Description:
Scheduled Weekly Hours:
40Shift:
Exempt/Non-Exempt:
United States of America (Exempt)Company:
SYSTEM West Virginia University Health SystemCost Center:
661 SYSTEM Clinical Denial Management
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