Denials and Appeals RN

Nebraska Methodist Health System - Omaha, NE

Full-time

Omaha, NE

Religious, Grantmaking, Civic, Professional, and Similar Organizations

About the position

The Denials and Appeals RN at Nebraska Methodist Health System is responsible for managing and communicating clinically-based appeals between the health system and payers. This role involves reviewing cases for appeal viability, constructing appeal letters, collaborating with physicians, and monitoring payer responses to ensure timely and effective resolution of denials. The position requires strong communication skills and a commitment to improving documentation of medical necessity, ultimately contributing to the overall quality of care provided to patients.

Responsibilities

• Promotes positive relations when interacting with physicians, visitors, families, customers, and co-workers.
• Responsible for overall management and communication of clinically-based appeals between Methodist Health System and payers.
• Reviews each case identified/referred for appeal.
• Utilizes InterQual and/or Physician Advisor to determine the viability of the appeal.
• Manages the appeal including documentation and communication to appropriate payer.
• Monitors for response and evaluates findings and rationale on denial and appeal tracking software when received.
• Constructs a letter of appeal arguing a clinically-oriented, objective and measurable rebuttal to denied days/services based on InterQual guidelines, payor guidelines, and/or Physician Advisor.
• Collaborates with Physician Advisor by delivering accurate clinical picture to assure appropriate decision is made to appeal.
• Demonstrates knowledge of appeal process for Medicare, Medicaid, and commercial payers.
• Constructs letters for all levels of appeal and adheres to payer timelines to ensure timely appeal.
• Communicates all pertinent information regarding denials of payment and/or levels of care to the billing office.
• Monitors, identifies, and reports suspected or emerging trends related to payer denials.
• Conducts pre-emptive audits of high-risk target areas and reports findings.
• Collaborates with Methodist Health System, its physicians, and its affiliates through communication with payers regarding medical necessity and institutional process issues.
• Facilitates communication among the Denials team members to solve problems at a personal and unit level.
• Acts as a resource and provides education/training to physicians, physician office staff, nurses, and coders.
• Participates in data collection for Denials & Appeals and assures that the data is reliable and valid.

Requirements

• Bachelors of Science in Nursing required.
• Registered Nurse (RN) with current state license is required.
• Five years clinical experience in medical surgical nursing and/or ICU or case management with strong computer skills to include Word and Excel.
• Past experience in an acute care setting as a Denials and Appeals RN preferred.
• Excellent communication skills; verbal, written and strong teaching skills, critical thinking skills and knowledge of healthcare delivery system.

Nice-to-haves

• Experience with InterQual guidelines and payer guidelines.
• Familiarity with denial tracking software.

Benefits

• Competitive pay
• Excellent benefits
• Great work environment where all employees are valued