• Registered Nurse RN Denials Management Specialist

    Job Number
    BH Corporate Office
    Case Mgmt-Corp
    Address : Street
    2901 North Central Ave
    Address : Location
    Work Schedule
    Position Type
    FT: Full-Time
    Posting Category
    Nursing - Case Management
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    Those who have joined the Banner mission come from all walks of life, united by the common goal: Make health care easier, so life can be better. If changing health care for the better sounds like something you want to be part of, we want to hear from you.


    Centralized Denial Recover.  This is the centralized team responsible for validating medical necessity for inpatient admissions or placement in observation.  We also work to mitigate potential admission and concurrent denials.  This team is heavily engaged in the Clinical Revenue Integrity initiatives.  Team members are held accountable to productivity metrics and held to a high level of accuracy.


    The RN Denials Management Specialist will be tasked with reviewing charts, outreach to attending physicians and insurance companies via phone. They will also be handling inbound concurrent denials for inpatient admissions. You will be for productivity metrics of seven reviews per day.


    Your pay and benefits (Total Rewards) are important components of your Journey at Banner Health. Banner Health offers a variety of benefit plans to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life.




    About Banner Health Corporate
    Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care.



    About Banner Health
    Banner Health is one of the largest, nonprofit health care systems in the country and the leading nonprofit provider of hospital services in all the communities we serve. Throughout our network of hospitals, primary care health centers, research centers, labs, physician practices and more, our skilled and compassionate professionals use the latest technology to make health care easier, so life can be better. The many locations, career opportunities, and benefits offered at Banner Health help to make the Banner Journey unique and fulfilling for every employee.


    Job Summary

    This position is responsible for providing support to the organizations Recovery Audit Contractor (RAC) program by reviewing clinical information and auditing billings to determine appropriateness of charges in accordance with CMS standards. In addition, this position provides oversight for the companys retrospective denial management process. This position promotes continual efforts to further the understanding of the complexities of federal, state and commercial regulatory coordination and provides leadership assistance to achieve optimal clinical, operational, financial, and satisfaction outcomes across the system as related to reimbursements.


    Essential Functions

    • Provides clinical expertise and oversight in the determination of the clinical appeals and denial management process resulting in significant savings for the organization. This position is a resource to the companys RAC team in responding to audit requests and serves to expedite the disposition of claims by reviewing charts and preparing appeals. In addition, this position authorizes the appropriate write off of claims that do not meet criteria for hospitalization. This position serves as primary educator for staff and physicians on regulatory compliance measures and in the use of clinical system criteria.


    • Evaluates and intervenes retrospectively for coverage issues, payor outliers, split billing, disallowed charges, incorrect DRG codes, denial and compliance issues.


    • Quantifies, analyzes, and monitors industry/Medicare trends in order to reduce denials and improve the financial outcomes for the organization. Makes recommendations for improvements based on these trends.


    • Serves as a resource and provides leadership assistance to achieve optimal clinical, operational, financial, and satisfaction outcomes across the system as related to federal, state and commercial reimbursements. Acts as a consultant across the organization to facilities with questions related to proper use of DRG codes.


    • Supports change and participates in the development, implementation and evaluation of the goals/objectives and process improvement activities across the organization as related to federal, state and commercial reimbursements.



    Minimum Qualifications

    Requires Registered Nurse (R.N.) licensure in the state of practice.

    Requires experience in federal, state and commercial reimbursements and in reviewing clinical information typically acquired in three years auditing DRG coding and reimbursements. Requires five or more years of clinical nursing and/or related experience. Experience in evaluation techniques, teaching, hospital operations, reimbursement methods, medical staff relations, and the charging/billing process is required. A working knowledge of utilization management and patient services is required. A working knowledge of Medical and third party payor requirements and reimbursement methodologies is required. Highly developed human relation and communication skills are required. Must demonstrate critical thinking, problem-solving, effective communication, and time management skills. Must demonstrate ability to work independently as well as effectively with team members.

    Must be proficient in the use of office desktop software programs.

    Preferred Qualifications

    BSN preferred

    Additional related education and/or experience preferred.

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