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Job Summary: The Denials RN is responsible for maintaining, researching and resolving reimbursement issues related to clinical denials for MercyOne across Iowa and surrounding owned and managed facilities. Responsibilities include applying clinical knowledge and expertise for prior authorization denials and claim denials and underpayments to achieve resolution and payment. Additional responsibilities include review of patient chart for necessary information, coordination of denial peer to peer reviews, calculation of expected reimbursement, segregation of insurance and patient responsibility, identification of actual underpayments and incorrect denials. Responsible for communication of clinical denial contract and reimbursement issues with payer, management and other departments including Admissions, Patient Accounts, HIM and Finance.
Essential Position Expectations:
Clinical review and dispute of post discharge concurrent prior authorization denials and claims denials/underpayments.
Researches, applies and offers guidance of in-depth clinical knowledge while performing the necessary tasks to overturn post discharge concurrent denials and recover reimbursement due to underpaid or denied claims including documenting recovery steps and other applicable information in patient chart, Managed Care database and patient accounting systems.
Determines appropriate reimbursement by utilizing patient chart, clinical expertise, applicable reimbursement methodology and rate schedules, as determined by hospital contractual arrangements, government fee schedules or other payment methodologies.
Engages and effectively communicates with payer, hospital staff including case management, utilization management and physician team in review of prior authorization denials and clinical claim denials and underpayments as well as arranging peer to peer review with physician and payer when necessary.
Evaluates and understands contractual language and health plan payment policies as it relates to payment compliance, reimbursement methodologies, and appeals processes.
Applies basic understanding of medical coding systems affecting the adjudication of claims payment. These include ICD-9, ICD-10, CPT, HCPCS, DRG, APG, APC, and revenue code structures.
Demonstrates proficiency with various reimbursement methodologies including, but not limited to, Per-Diem, DRG, fee schedule, percentage of charges, and stop loss.
Monitors payer specific changes in claims submission clinical requirements and provides routine updates to MercyOne.
Maintains the ability to understand and utilize a complex and highly sophisticated billing system and related programs.
Supports MercyOne Payer Strategy team providing clinical knowledge and expertise to assist in team member task completion.
Education: 2 year degree for current licensure as a registered nurse of Iowa. BSN or 4 year degree in healthcare field preferred. Medical office/claims billing past work knowledge strongly preferred.
Experience: Minimum of five (5) years prior clinical nursing experience. Background in financial healthcare reimbursement is strongly preferred, including an understanding of diagnosis and procedure coding, billing practices, and payment methodologies.
Managed care knowledge preferred. ICD 10 experience preferred.
Certifications & Licenses: Current licensure as a registered nurse of Iowa.Additional Information
- Requisition ID: 2019-R0232083
- Schedule: Full-time
- Shift: Day Job
- Market: CHI Mercy Health
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