Job Title: Case Appeals RN
Company: Good Samaritan Hospital
City/State: Suffern, NY
Category: Nursing/Nursing Management
Department: Care Management
Position: Full Time
Req #: 19029
Posted Date: Aug 28, 2020
The Case Appeals RN is responsible for management of the process of appealing clinical denials and reviewing denials to the insurance provider.
Contributes to the development of all workflows and internal processes regarding appeals processes. Meets routinely on an as needed basis with payers for “meet and confer” meetings as appeals progress through various levels of review, working with payer clinical resources to resolve cases. Develops relationships with Case Management Leadership and Medical Directors as needed to assure consistent approach and application of clinical decision making regarding denials. Prepares outcome reports related to level of appeal overturns versus upheld decisions Maintains a current working knowledge of coding and reimbursement rules and regulations and clinical criteria to be met for coverage. Approves the work schedule, time off requests and supply orders. Hires and trains new employees. Approves staff performance evaluations and initiates corrective actions as needed
Qualifications / Requirements:
A minimum of 5 years of supervisory experience in Denials, Utilization Management, Case Management or any combination preferred including interpretation of hospital medical documentation (i.e., EMR).
A Bachelor’s degree in Nursing, or Associate’s degree in Nursing with clinical specialty certification, additional Utilization Management or Case Management experience as noted under experience may substitute degree requirement
Licenses / Certifications:
New York State RN license required
Working knowledge of utilization management, case management and process improvement. Working knowledge and use of evidenced based guidelines. Understanding of reimbursement methodologies and terms. Knowledge of industry trends in Managed Care and familiarity working with contracts and payment rules. Expertise in insurance, managed care and federal/ state coverage. Must have base knowledge of clinical coding and reimbursement and/or claims management.