Revenue Integrity Analyst II - Denial Management

Bronson Healthcare

2d

About The Position

The Denials Management Specialist assesses and utilizes clinical and financial information in relation to appealing, trending, and educating the Bronson Healthcare Group (BHG) system on retrospective denials and /or non-payment of claims. In partnership with patients, physicians and other health care providers, support the utilization of resources and obtain optimal reimbursement to assure maximum appropriate reimbursement for the organization. This includes reviewing denials of reimbursement based on medical necessity utilizing professional knowledge, expertise, application of reimbursement methodology, third-party contract language and industry accepted criteria and guideline sets (i.e., Interqual). Responsible for creating effective appeal letters utilizing relevant and effective clinical documentation from the medical record. Employees providing direct patient care must demonstrate competencies specific to the population served.

Requirements

• Bachelor's degree in Nursing or equivalent experience and 3-5 years experience, preferably with managed care, denials management and/or charge capture, required.
• Licensed Registered Nurse in good standing for the State of Michigan and/or a minimum of 10 years nursing experience in an acute care facility , certified coding credentials preferred (CCS, CPC, etc.)
• Knowledge of the operations of patient billing and payer grievance procedures.
• Demonstrated knowledge of insurance plans (i.e., commercial, Medicare, HMO/PPOs, etc.)
• Excellent oral and written communication skills.
• Ability to apply medical necessity criteria based on payor requirements.
• Working knowledge of managed care principles and regulatory requirements and case management/discharge planning
• Demonstrates excellence in the areas of leadership, teamwork, customer services, quality, and contributes to the organizations financial success
• Demonstrates the ability to coordinate multiple functions.
• Ability to utilize word processing, spreadsheet, presentation programs, and other software relevant to the job.
• Regularly utilizes effective negotiation and conflict resolution skills
• Work which produces levels of mental/visual fatigue which are typical of jobs that perform a wide variety of duties with frequent and significant uncontrollable deadlines.
• Work may include the operation of and full attention to a personal computer or CRT up to 40 percent of the time.
• The job produces some physical demands. Typical of jobs that include regular walking, standing, stooping, bending, sitting, and some lifting of light weight objects.

Responsibilities

• Formulate and submit letters of appeal.
• Create an effective appeal utilizing relevant and effective clinical information from the medical record, and supported by current industry clinical guidelines, community and national medical management standards and protocols.
• Review denials of reimbursement based on medical necessity utilizing professional knowledge, expertise, application of reimbursement methodology, and industry accepted national criteria and guideline sets (i.e., Interqual), and contract language.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level