Payer Audit Appeal RN Job Listing at Lexington Medical Center in West Columbia, SC (Job ID 1308512200)

Description

Managed Care & Payer Relations  
Full Time
Day Shift 
40.00

Consistently named best hospital, Lexington Medical Center dedicates itself to providing quality health services that meet the needs of its communities. Ranked #1 in the Columbia metro area by U.S. News & World Report, Lexington Medical Center is the only hospital named one of the Best Places to Work in South Carolina and the first hospital in the state to achieve Magnet with Distinction status for excellence in nursing care.

The 607-bed teaching hospital anchors a health care network that includes six community medical centers and employs more than 8,700 health care professionals. The network includes a cardiovascular program recognized by the American College of Cardiology as South Carolina's first HeartCARE CenterTM and an accredited Cancer Center of Excellence affiliated with MUSC Hollings Cancer Center for research and education. The network also features an occupational health center, the largest skilled nursing facility in the Carolinas, an Alzheimer's care center and nearly 80 physician practices.  Its postgraduate medical education programs include family medicine and transitional year.

Responsible for timely appeal of all insurance payer clinical and authorization denials and/or audit denials for medical necessity and DRG/coding validation.  Works collaboratively with Utilization Management, Health Information Management, Internal Audit, Risk Management, and other ancillary departments to respond to and appeal payer denials as indicated. Performs analysis of denial data to identify inefficient routines, processes and systems which do not contribute to desired financial outcomes and makes recommendation regarding action to change these practices. Identifies patterns or recurring trends with payers that consistently deny claims and communicates this information to leadership as indicated.

Minimum Education: Associate's Degree 
Minimum Years of Experience: Three years of experience in hospital nursing
Substitutable Education & Experience (Optional): None
Required Certifications/Licensure: Currently licensed as Registered Nurse by the State Board of Nursing for South Carolina.
Required Training: Excellent verbal/written communication skills

• Coordinates all activities related to monitoring and appealing authorization and/or medical necessity denials either received from insurance claim processing, Recovery Audit Contractors or other Payer Audits.
• Refutes or substantiates third party payers' denials or audit findings based on review of relevant medical documentation.
• Works with Utilization Review, Discharge Planning and HIM to determine whether coding and billing is supported by the clinical documentation in the medical record, and coordinates with these areas to write complete and comprehensive appeals to support claims as needed.
• Research payer medical policies effecting reimbursement and report findings to the appropriate parties.
• Functions as a liaison between Managed Care & Payer Relations Department and the entire health district (including acute care, MSO, CMCs and Extended Care departments) as a resource for payer authorization processes, medical necessity/authorization complaints, denials and grievances.

• Ensures proper documentation of activity or progress in EPIC and/or denial tracking software to  ensure that anyone viewing accounts will be aware of current status.
• Ensures timely resolution of all denials, including escalation of denials resolution via monthly operational conference calls, as needed.
• Develops and maintains policies and procedures for the review, appeal and follow up on Payer denials and related activities.
• Analyzes trends in denials and then work with appropriate areas to resolve root causes identified.
• Identifies potential areas of vulnerability and risk, work with departments or practice managers to develop/implement plans for resolution of problematic issues, and work to avoid similar issues in the future.
• Provides reports on a regular basis, and as requested, to keep the organization and senior management informed of trends and efforts to prevent and address denials.
• Will communicate appropriate Payer denial and/or process information to senior management to facilitate contract negotiation or renegotiation of existing contracts.
• Coordinates monthly Denial Prevention or Audit Committee meetings to discuss, provide details, and offer solutions for old, current or new issues that arise as a result of Payer Audits and/or Denials.
• Provides information required to achieve government settlement of appeals, as needed.
• Other duties as assigned

We are committed to offering quality, cost-effective benefits choices for our employees and their families:

• Day ONE medical, dental and life insurance benefits 
• Health care and dependent care flexible spending accounts (FSAs)
• Employees are eligible for enrollment into the 403(b) match plan day one.  LHI matches dollar for dollar up to 6%.
• Employer paid life insurance – equal to 1x salary
• Employee may elect supplemental life insurance with low cost premiums up to 3x salary 
• Adoption assistance
• LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment
• Tuition reimbursement
• Student loan forgiveness

Equal Opportunity Employer
It is the policy of LMC to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. LMC strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. LMC endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee's desires and abilities and the hospital's needs.