Denial Resource Center RN

Job Description

JOB SUMMARY

The Denial Resource Center Registered Nurse (RN) is responsible for Baylor Scott & White Health denial management functions. The Denial Resource Center (DRC) is responsible for receiving claim denials and appealing to payors to promote appropriate reimbursement from payors to BSWH hospitals. The DRC RN manages denials from all payors, including denials for lack of medical necessity, pre-cert, re-cert, billing, coding, and patient status.

ESSENTIAL FUNCTIONS OF THE ROLE

Review coding and clinical denials to ensure accuracy and compliance with guidelines.

Write effective appeals using coding standards, clinical documentation, and medical protocols.

Identify denial trends and root causes related to coding or documentation.

Maintain expert knowledge of Coding and CDI practices.

Receives clinically denied claims from the BSWH Central Business Office, or directly from the payor, and appeals the denied claim through all appropriate levels of appeal as defined by the payor.

Reviews the denied patient's medical record to analyze the following in order to appeal the denied claim : Appropriate level of care, appropriate admission status, medical necessity for the hospitalization, appropriate application of InterQual criteria, appropriate LOS and discharge planning

Reviews and any associated physician office records that may assist with the appeal process and / or regulatory documentation requirements.

Engages the attending and consulting physicians as well as the Care Coordination Medical Directors when needed to assist in appeal writing.

Performs chart analysis on quality surveillance and special studies as requested, i.e. Novitas, OIG, CMS probes.

Identifies opportunities for and participates in process improvement.

Identifies denial trends by DRG, type, procedure, etc.

Assists leadership in developing medical necessity documentation forms to meet regulatory requirements.

Participates in pertinent meetings, including hospital AWO meetings, to share denial trends and activities seen within the DRC with key stakeholders.

Documents denial information and appeal findings into the DRC electronic system for analysis of denial trends and appeal outcomes.

KEY SUCCESS FACTORS

Understands commercial and government regulations for reimbursement including, but not limited to : InterQual, RAC / MAC, Clinical Policy Bulletins, national and local coverage determinations, CMS admission status requirements, TJC conditions of participation, CMS appeals process, including Administrative Law Judge.

Knowledge and understanding of nursing and patient care standards and procedures.

Knowledge of laws, rules and regulations; standards and guidelines of certifying and accrediting bodies; hospital and department / unit standards, protocols, policies and procedures governing the provision of nursing care applicable to the area of assignment.

Knowledge of medical terminology; principles and practices of health promotion, risk reduction, illness and disease prevention and management; medications and drugs, common dosages, their physical and physiological effects, and possible adverse reactions.

Knowledge of medical and professional nursing ethics and patient privacy rights.

Must be able to communicate thoughts clearly, both verbally and in writing.

Interpersonal skills to interact with a wide-range of constituencies.

Must have critical thinking and problem-solving skills.

Ability to observe changes in the medical condition of patients and effectively communicate these changes to other nursing staff members and physicians / providers.

Ability to provide age-specific, quality, patient-centered care to all patients through the nursing process and standards of nursing practice with sensitivity and respect for the diversity of human experience and to develop, evaluate, implement and, as necessary, modify a patient care plan to meet the needs of individual patients.

General computer skills, including but not limited to : Microsoft Office, information security, scheduling and payroll systems, electronic medical documentation, and email.

ACM or CCM license preferred.

BENEFITS

Our competitive benefits package includes the following

• Immediate eligibility for health and welfare benefits
• 401(k) savings plan with dollar-for-dollar match up to 5%
• Tuition Reimbursement
• PTO accrual beginning Day 1

Note : Benefits may vary based upon position type and / or level

QUALIFICATIONS

Registered Nurse (RN)

Hybrid expectation- On-site once a year

Experience with CDI preferred