Denials/Appeals Nurse

Denials/Appeals Nurse

Denials/Appeals Nurse
Department: Continuity of Care
Schedule: Full time
Shift: Day shift
Hours: Monday-Friday, days
FTE:
Salary:
Job Details:
* Experience Necessary
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POSITION SUMMARY:
The Denials and Appeals RN Coordinator under the supervision of the Director of Continuity of Care and the Director of the Revenue Cycle performs services in a designated area according to the policies, procedures, philosophy, and objectives of the department and hospital. The professional nurse practices in accordance with the Massachusetts Nurse Practice Act, American Nurses Association scope and Standards of Practice, Quality Caring Model and professional practice model atLowellGeneralHospital. Works cooperatively within department and other services to create a system of quality health care.


POSITION RESPONSIBILITIES:
The Denials and Appeals RN Coordinator under the general supervision of the Director of Continuity of Care and the Director of Revenue Cycle is responsible and accountable for the management of denials and appeals for the entire patient population across the continuum of care. The Denials and Appeals RN Coordinator supports denials, appeals and compliance activities within the Continuity of Care Department and the Revenue Department.




ASSESSMENT

* Performs daily review of non elective short stays (48hours or less)
* Uses Interqual criteria to assign Admission Status to all patients, monitors status and changes as necessary through continued stay review and discharge screens.
* Performs pre-admission surgical review to monitor admission status, assist with ABNs or HINNs for elective non covered Medicare procedures and reviews the Medicare Inpatient Only Procedure list.
* Assesses the need for a formal appeal of all denials preadmission, admission, concurrent and retro andadhere to all appeal timelines as prescribed by payer agreements.
* Assesses the need for a formal appeal on outpatient denials and conducts formal appeal when appropriate.


IMPLEMENTATION
* Follows all policies and procedures for CMS (Center for Medicare and Medicaid Services)
* Gains knowledge of all existing payer contracts and actively participates in discussions with managed care organizations as issues regarding denials arise.
* Establishes relationships with key payers that contract with the hospital.
* Coordinates activities related to financial/insurance issues including providing clinical updates to third party payers.
* Researches, organizes and maintains case management functions related to appeal writing and the Observation process.
* Acts as liaison between the Case Management Department and other appeal related internal and external departments/organizations.
* Acts as primary resource for case managers regarding appeals, concurrent denials and the management of Observation status.
* Tracks, identifies and educates trends in the utilization of Observation status both internally and by payers to identify needs for organizational practice changes.
* Acts as liaison to PatientAccountsand Patient Access departments to disseminate appeal related information.
* Acts as liaison to the Admitting department for appropriate status of short stay non-elective admissions.
* Acts as member of the RAC committee.
* Works closely with department leaders and the revenue cycle staff to identify and develop broad performance improvement plans to address identified issues and areas of risk.

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EVALUATION
oUtilizes ongoing assessment data to revise interventions, outcomes and documents accordingly.
oMaintains Denial and Appeal log.
oReports quarterly to the Utilization Review Committee on denial and appeal status.
oReports quarterly to the case management staff on statistics by payer.
* Tracks appeal success by payer and reports success on a monthly basis to the Director of Revenue Cycle.
oEnsures that hospital and department policies and procedures are followed and assists with the development of new policies and procedures and training guides.


PROFESSIONAL STANDARD
Demonstrates through work performed, a thorough knowledge of and adherence to the evidenced based standards of nursing care, and the policies and procedures of the hospital and nursing division.
oDemonstrates understanding of Shared Governance by providing input, feedback and participation to assure autonomy competence and accountability.
oTeaches others to succeed by mentoring, in servicing, role modeling, precepting, orienting, and facilitating peer development.
oSeeks guidance and resources when necessary in the management of denials and appeals and Observation process.
oThe Denials/Appeals nurse evaluates his/her own nursing practice in relation to professional practice standards and evidence based care using the 360 evaluation process.
oAttends all mandatory educational programs and skills day.
oMaintains current knowledge of payer Observation Policies
oSupports clinical operations of the department by providing appropriate appeals, denials and Observation status education to case management staff and revenue cycle staff.

QUALITY
Uses the results of quality improvement activities, creativity and innovation to improve patient care.
* Participates in specific Quality improvements including nurse sensitive indicators, national patient safety goals, core measures and other specific indicators being monitored.
* Delivers quality care in a manner that preserves and protects patient autonomy, dignity, rights, confidentiality, privacy and security.

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