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Denials and Appeals Nurse

Washington, DC
POSITION SUMMARY:
 
Under the general direction and guidance of the manager and supervisor of the Denials & Appeals Department, conducts retrospective chart reviews for clinical, financial, and resource utilization information. Writes appeals letters in an effort to overturn denial of payment for services rendered.
 
REPORTING SUMMARY:  
 
This position reports to the Supervisor for Denials & Appeals
 
PRINCIPAL ACCOUNTABILITIES:
 
  • Research payer denials related to referral, pre-authorization, medical necessity, case management, non-covered services, and billing resulting in denials and delays in payment.
  • Summit detailed, appeals to payers based on review of medical records and in accordance with Medicare, Medicaid and third-party guidelines as well as Howard University Hospital policies and procedures.
  • Identifies and reports on the categorization of denials, suspected or emerging trends related to payer denials and/or slow payment, and coordinates with manager/supervisor to develop strategy for correction and process changes to eliminate avoidable denials.
  • Provide telephonic assessment and evaluation to determine appropriate admission criteria for Hospital physicians and outside facilities requesting direct admission.  
  • Assumes other duties and responsibilities that are related and appropriate to the position and area.  The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered at all-inclusive.
 
 
 
ORGANIZATIONAL EXPECTATIONS:
 
  • Promotes adherence to the Health Sciences Compliance Program, the Howard University Code of Ethics and the Health Sciences Standards of Conduct.
  • Attends annual and periodic mandatory Compliance Program training including the Health Insurance Portability and Accountability Act (HIPAA) training.
  • Participates in activities that promote adherence to federal healthcare program requirements.
  • Actively participates in Health Sciences Compliance Program activities.
  • Adheres to the requirements of the HIPAA Privacy Policies and Procedures.
  • Maintains confidentiality of patients, families, and staff.
 
CARES CRITERIA:
 
  • Must demonstrate collaboration; accountability; respect; excellence; and service.
  • Works with team members and peers in and outside of their immediate work group to create an exceptional experience for patients, students and other visitors.
  • Accepts responsibility for his/her actions to provide health care and/or ancillary functions in a highly efficient and compassionate manner.  The employee must function as a Steward of Howard values that foster a commitment to improving the patient and student experience, organizational efficiency and the environment.
  • Embraces diversity and cares holistically for those the Hospital serves.
  • Manages the patient’s right to privacy with meticulous care and keeps patient and proprietary information about the institution confidential.
  • Anticipates the patients’ and students’ needs, presents as a model representative of the institution and maintains high standards of care while striving to improve performance and create exceptional experiences for our customers.
  • Conduct oneself in a friendly, resourceful and professional manner towards all Howard University employees and vendors. In addition, show respect to patients, students and visitors in the same way that they would want their family members or themselves to be treated.
 
CORE COMPETENCIES:
  • Demonstrate proficiency using evidence-based clinical decision support solutions (i.e. InterQual/MCG) to make appropriate medical utilization decisions relevant to inpatient/outpatient acute care, and payer denial and appeal processes.
  • Must be able to exercise independent discretion and judgment, and act at all times with the highest degree of professionalism and objectivity.
  • Must be computer literate and able to manage Outlook, Word and Excel programs, prepare charts and graphs, and analyze data to identify trends and opportunities for process improvement.
  • Knowledge of various spreadsheet applications, including Microsoft Word.  Knowledge of billing requirements related to charges. 
  • Ability to establish and maintain effective and harmonious work relationships with staff, physicians, Hospital and University officials, and the general public. 
MINIMUM REQUIREMENTS:
  • Bachelor’s degree in Nursing required; Master’s degree preferred
  • Current nursing license in good standing. If not an active Washington, DC nursing license, would need to become certified in Washington, DC upon hire.  Certification in case management or denial management preferred.
  • Two years (2) direct patient care experience as an RN in an acute care setting. Two years (2) of experience working with denials and appeals, utilization review, and case management in an acute care setting.
 
PHYSICAL DEMANDS:
  •  Must be able to use a computer keyboard and mouse 6-8 hours per day
  • Must be able to dial, answer and talk on the telephone for 6-8 hours per day
  • Must be able to lift and transport 20 pounds occasionally and/or up to 10 pounds frequently
 
The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.
 
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