RN Denial Management Specialist

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A rewarding career that fits your life. Those who have joined the Banner mission come from all walks of life, united by the common goal: Make health care easier, so life can be better. If changing health care for the better sounds like something you want to be part of, apply today.

In Centralized Denials Management, we assist our patients by working with insurance payers to get clinical services covered. Our team functions with reasonable goals, a positive team environment, consistent communication from team members and leadership, and a focus on helping you develop and succeed.

This role is a remote working experience, where the bedside is a review of the medical record and the treatment plan is to overturn denials. In this unique nursing opportunity, we utilize multiple systems and established processes to achieve this goal, and we have shown very strong overturn denial rates for the past 12 months.

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.


Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers of Banner Health with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.

NOTE: The core functions are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Specific tasks or responsibilities will be documented as outlined by the incumbent's immediate manager.

SUPERVISORY RESPONSIBILITIES
DIRECTLY REPORTING
None
MATRIX OR INDIRECT REPORTING
None
TYPE OF SUPERVISORY RESPONSIBILITIES
N/A

Banner Health Leadership will strive to uphold the mission, values, and purpose of the organization. They will serve as role models for staff and act in a people-centered, service excellence-focused, and results-oriented manner.


PHYSICAL DEMANDS/ENVIRONMENT FACTORS
OE - Typical Office Environment: (Accountant, Administrative Assistant, Consultant, Program Manager)
Requires extensive sitting with periodic standing and walking.
May be required to lift up to 20 pounds.
Requires significant use of personal computer, phone and general office equipment.
Needs adequate visual acuity, ability to grasp and handle objects.
Needs ability to communicate effectively through reading, writing, and speaking in person or on telephone.
May require off-site travel

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.

DATE APPROVED 03/10/2009