Working under the direction of the Denials Manger and as a member of the Denials Team, is chiefly responsible for the management of admission and readmission denials that can occur preadmission, concurrently or retrospectively. The Denials Coordinator in collaboration with the Physician Advisor will prepare and send formal appeals. Will collaborate with various medical center departments and act as a clinical resource. Responsible for tracking and reporting denial trends. Will develop and implement denial prevention strategies. The Denial Coordinator will assist the Denials Team in appealing other denials as needed.
- In collaboration with the Physician Advisor, assesses the need for formal appeals for preadmission, concurrent and retrospective denials.
- Understands denial reasons and rationale.
- Prepares and sends well written appeals based on clinical evidence within the medical record and evidence-based literature.
- Requests and obtains medical records, notes, financial billing statements and other necessary documentation to accompany and compliment the formal appeal.
- Works with Patient Financial Services on status of appeals and updates as needed.
- Understands appeal levels per payer and utilizes all appeal options available.
- Manages and refers cases that have exhausted all appeals to Managed Care for arbitration.
- Enters denials and requests for appeals into system. Tracks appeal progress. Keeps appeal statuses up to date.
- Completes denial assignments with specified due dates.
- Consults with Patient Financial Services, Coding, Physician Advisor, Managed Care and ancillary departments on complex denial issues.
- Acts as a liaison between the Denials Team and external organizations.
- Acts as a liaison between the Denials Team and departments within CentraState Medical Center.
- Acts as a liaison between the Denials Team and the Care Coordination Department.
- Operates as a clinical resource for Coding, Patient Financial Services, Managed Care and Denials Management.
- Operates as a clinical resource for Managed Care led Arbitration.
- Functions as a resource for Care Coordinators regarding appeals, concurrent denials and regulatory audits.
- Responsible for regulatory audits assigned by Denials Manager. Reviews documentation, provides preliminary assessments and oversees process for sending required documentation for the audit. Responsible for reviewing results of audit and writing formal appeals as needed.
- Analyzes data from audit findings, facilitates action plans to correct issues and reports that to Denials Manager. Assists with presenting corrective action plan to affected departments.
- Keeps current and notifies applicable parties of changes in federal, state and/or third party payer rules and regulations.
- Keeps current and notifies applicable parties of changes in department and hospital policies and system updates.
- Upon request of Denials Manager, prepares narratives, graphs, flowcharts and organizes information to be used for presentations.
- Using critical thinking skills along with historical and current data, presents opportunities for denial prevention to Denials Manager.
- Assists the Denials Manager with presenting denial prevention opportunities.
- Assists the Denials Manager and Revenue Integrity Nurse Auditors with other denials (DRG downgrades, Outpatient Denials) as needed.
Bachelor’s Nursing Preferred
3 Years’ Clinical Experience Required
Denials, Care Coordination, or Clinical Documentation Improvement (CDI) experience preferred
Licenses and Certifications:
RN License / New Jersey Required
CCM certification Preferred
Required Knowledge and Skills:
Strong broad-based clinical knowledge and understanding of pathology/physiology of disease process. Highly effective verbal, written and analytical skills with the ability to work independently. Ability to work successfully with a diverse group of staff at various levels with the organization. Excellent critical thinking skills. Excellent interpersonal skills to build effective partnering relationships with hospital staff. Knowledge of care delivery documentation systems and related medical record documentation. Proficient in denials management software. Proficient in Microsoft Office (Word, Excel, Outlook, etc).
Works in a normal hospital environment.
No expected exposure to blood and/or body fluids.
Sitting – Continuously
Standing/Walking – Occasionally
Kneeling/Stooping – Rarely
Bending/Climbing – Rarely
Reaching above shoulder, at waist or below waist – Never
Lifting/Pushing or Pulling up to 40 pounds – Never
Lifting/Pushing or Pulling over 40 pounds – Never
Typing/Filing – Continuously
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
CentraState Healthcare System prohibits discrimination based on arbitrary consideration of such characteristics such as race, color, religion, national origin, ancestry, gender (including pregnancy), affectual or sexual orientation, gender identity or expression, marital status, age, physical or mental disability or limitation, medical condition, genetic information, or veteran or military status, as well as any other legally protected class of persons and acts, in accordance with applicable State and Federal laws.
At CentraState, we welcome and promote the diversity of our employee family! Each unique person contributes to the overall success of this organization. Our inclusive culture fosters an environment of professionalism and respect for personal differences.
Additionally, CentraState Healthcare System prohibits discrimination based on arbitrary consideration of such characteristics such as race, color, religion, national origin, ancestry, gender (including pregnancy), affectual or sexual orientation, gender identity or expression, marital status, age, physical or mental disability or limitation, medical condition, genetic information, or veteran or military status, as well as any other legally protected class of persons and acts, in accordance with applicable State and Federal laws.