Denials and Appeals RN

Nebraska Methodist Health System - Omaha, NE

Full-time - Mid Level

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. The RN will also educate staff on documentation practices and trends related to payer denials, ensuring compliance with regulations and improving the overall Denials & Appeals process.

Responsibilities

• Promote positive relations when interacting with physicians, visitors, families, customers, and co-workers.
• Manage overall communication of clinically-based appeals between Methodist Health System and payers.
• Review cases identified for appeal and utilize InterQual and/or Physician Advisor for viability.
• Manage documentation and communication to appropriate payers regarding appeals.
• Monitor responses and evaluate findings on denial and appeal tracking software.
• Perform reviews of patients in the acute care setting for Medicare, Medicaid, and commercial payers.
• Construct letters of appeal based on clinical guidelines and payer requirements.
• Collaborate with Physician Advisor to ensure accurate clinical information is presented in appeals.
• Communicate pertinent information regarding denials to the billing office.
• Monitor and report trends related to payer denials.
• Conduct pre-emptive audits of high-risk areas and report findings.
• Facilitate communication among Denials team members to solve problems effectively.
• Provide education and training to physicians and staff on documentation and appeal processes.
• Participate in data collection for Denials & Appeals and ensure data reliability.

Requirements

• Bachelor of Science in Nursing required.
• Registered Nurse (RN) with current state license is required.
• Five years of clinical experience in medical-surgical nursing and/or ICU or case management.
• Strong computer skills including Microsoft Word and Excel.
• Excellent verbal and written communication skills.
• Strong teaching and critical thinking skills.

Nice-to-haves

• Past experience in an acute care setting as a Denials and Appeals RN preferred.

Benefits

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