RN Denial Management Specialist

Department Name: Denial Recovery-Corp Work Shift: Day Job Category: Revenue Cycle Explore and excel. At Banner Health, health care is a team effort. One might be surprised by the number of people who work behind the scenes and play a critical role in ensuring the best care for our patients. The mission of the Denial Management Department is to, “Manage denied insurance claims by analyzing medical records, crafting clinical appeals, and collaborating with payers to secure reimbursement.” This team works within Revenue Cycle to identify denial trends, ensure compliance, and minimize financial losses; requiring expertise in coding, medical necessity, and payer regulations. A successful RN Denial Management Specialist will need to have a minimum of 5 years clinical nursing experience, preferably in Case Management and/or Utilization Review as well as an active RN licensure in state worked. This is a fully remote position and available if you live in the following states only: AK, AL, AR, AZ, CA, CO, FL, GA, IA, ID, IN, KS, KY, MI, MN, MO, MS, NC, ND, NE, NM, NV, NY, OH, OK, OR, PA, SC, TN, TX, UT, VA, WA, WI & WY. In this remote role, candidates must be self-motivated, possess moderate to strong tech skills and be able to meet daily and weekly productivity metrics. You are required to work at least 75% of your shift within 7AM to 5PM AZT/MST. No holidays or weekends. Business hours are Monday-Friday, 8 hour shifts with no weekends or holidays. Your pay and benefits (Total Rewards) are important components of your Journey at Banner Health. Banner Health offers a variety of benefit plans to help you and your family. We provide health and financial security options so you can focus on being the best at what you do and enjoying your life. Apply today! Within Banner Health Corporate, you will have the opportunity to apply your unique experience and expertise in support of a nationally-recognized healthcare leader. We offer stimulating and rewarding careers in a wide array of disciplines. Whether your background is in Human Resources, Finance, Information Technology, Legal, Managed Care Programs or Public Relations, you'll find many options for contributing to our award-winning patient care. POSITION SUMMARY This position is responsible for providing support to the organization’s Recovery Audit Contractor (RAC) program by reviewing clinical information and auditing billings to determine appropriateness of charges in accordance with CMS standards. In addition, this position provides oversight for the company’s retrospective denial management process. This position promotes continual efforts to further the understanding of the complexities of federal, state and commercial regulatory coordination and provides leadership assistance to achieve optimal clinical, operational, financial, and satisfaction outcomes across the system as related to reimbursements. CORE FUNCTIONS 1. Provides clinical expertise and oversight in the determination of the clinical appeals and denial management process resulting in significant savings for the organization. This position is a resource to the company’s RAC team in responding to audit requests and serves to expedite the disposition of claims by reviewing charts and preparing appeals. In addition, this position authorizes the appropriate write off of claims that do not meet criteria for hospitalization. This position serves as primary educator for staff and physicians on regulatory compliance measures and in the use of clinical system criteria. 2. Evaluates and intervenes retrospectively for coverage issues, payor outliers, split billing, disallowed charges, incorrect DRG codes, denial and compliance issues. 3. Quantifies, analyzes, and monitors industry/Medicare trends in order to reduce denials and improve the financial outcomes for the organization. Makes recommendations for improvements based on these trends. 4. Serves as a resource and provides leadership assistance to achieve optimal clinical, operational, financial, and satisfaction outcomes across the system as related to federal, state and commercial reimbursements. Acts as a consultant across the organization to facilities with questions related to proper use of DRG codes. 5. Supports change and participates in the development, implementation and evaluation of the goals/objectives and process improvement activities across the organization as related to federal, state and commercial reimbursements. 6. Corporate based position with no budgetary responsibility. Internally, this position interacts with physicians, clinicians correct and management across the system. Externally, this position interacts with RAC Auditors and other organizations. MINIMUM QUALIFICATIONS Requires Registered Nurse (R.N.) licensure in the state of practice. Requires experience in federal, state and commercial reimbursements and in reviewing clinical information typically acquired in three years auditing DRG coding and reimbursements. Requires five or more years of clinical nursing and/or related experience. Experience in evaluation techniques, teaching, hospital operations, reimbursement methods, medical staff relations, and the charging/billing process is required. A working knowledge of utilization management and patient services is required. A working knowledge of Medical and third party payor requirements and reimbursement methodologies is required. Highly developed human relation and communication skills are required. Must demonstrate critical thinking, problem-solving, effective communication, and time management skills. Must demonstrate ability to work independently as well as effectively with team members. Must be proficient in the use of office desktop software programs. PREFERRED QUALIFICATIONS BSN preferred. Additional related education and/or experience preferred. Estimated Pay Range: $37.14 - $61.90 / hour Banner Health is committed to pay equity and transparency. The posted compensation range is a reasonable estimate that extends from the lowest to the highest pay Banner Health in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. This range is based on possible base salaries and does not include the value of our total rewards package. Actual pay determined at offer will be based on years of relevant work experience, education, certifications, skills, and geographic location, along with a review of current employees in similar roles to ensure pay equity is achieved and maintained. EEO Statement: EEO/Disabled/Veterans Our organization supports a drug-free work environment. Privacy Policy: Privacy Policy Apply To This Job