Massachusetts Healthcare Jobs

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Type:

Regular

Scheduled Hours:

40

Work Shift:

Day (United States of America)

The Denials and Appeals RN is responsible for coordinating appeals and denials from all payers i.e.; Medicare, Medicaid, and Commercial. This includes both inpatient, and observation payments. The RN reviews all denials received for medical necessity, investigates and reviews appropriate guidelines including LCD/NCD and UM guidelines, and composes a clinically based appeal to overturn payer denials.

Job Description:

ESSENTIAL DUTIES

1. Reviews medical records and collects, organizes, and presents pertinent clinical information in an appeal format.

2. Responsible for tracking all denial cases and cases in appeal for performance measurement and outcome purposes, including data for accurate reporting and statistical purposes, in the appropriate IT system. Collaborate and share information with the Revenue Cycle team to ensure reimbursement for services provided.

3. Utilizes appropriate screening tools and policies such as InterQual, LCD/NCD, and Commercial Insurance UM guidelines.

4. Familiarity with remittance advice, UB04, CMS IPPS/OPPS.

5. Responsible for appealing all inappropriate denials through all possible levels of appeal. Arrange and prepare physicians for peer review.

6. Responsible for reviewing claim denials received through the CMS Recovery Audit Contractor and Medicaid Integrity Contractor. Performs focused first level review based on established criteria for that year, determines status of second level review and strength of appeal. Report’s findings and collaborates with UR committee.

7. Stays current on all regulatory changes related to resource utilization and shares learning with appropriate stakeholders to meet organization requirements and regulatory demands. Provides resources and expertise to Care Transitions, Billing and Medical Records as a regulatory/payer expert.

8. Provides education as needed and applicable to clinical staff, and other departments.

9. Analyzes all medical necessity denials to identify trends, opportunities, and education feedback needed. This includes feedback to patient access, coding, billing, HIM, other departments, and physician offices.

Qualifications:

Required

• Licensure as a Registered Nurse (RN), Massachusetts

• Three years of recent Denial/Appeals or utilization management experience

Preferred:

• Bachelor’s degree in nursing or related healthcare fields.

• Competence in standardized medical necessity criteria

• ACM, CCM, or CMAC Certification

Knowledge, Skills, and Abilities:

1. Demonstrates expertise in the appeal process, utilization management principles, methods, and tools and incorporates them into the daily operations of the organization.

2. Understands, interprets and explains, and uses data for utilization management activities.

3. Applies the principles and methods necessary to perform utilization management functions.

4. Competency in applying the principles, methods, materials, and equipment necessary in

providing utilization management services.

1. Demonstrates clinical expertise to effectively facilitate the evaluation of the level of care required.

2. Develops and maintain strong collaborative working relationships with physicians, nursing colleagues, and Revenue Cycle team.

3. Provide and receive feedback in a positive and constructive manner.

4. Ability to understand, interpret, and explain data for utilization management functions

5. Demonstrates highly developed written, verbal, and presentation skills.

6. Possesses knowledge of care delivery systems across the continuum of care, including trends and issues in care reimbursement.

7. Possesses mid to high-level proficiency in navigating the Electronic Medical Record and applications related to utilization management.

8. Compliance with the Code of Ethics and Guide for Professional Conduct.

FLSA Status:

Non-Exempt

As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled