Denial/Appeal Management Nurse Remote

University Hospitals Pain Management; Shaker Heights (OH); Remote; USD 50,000 - 75,000; Full time

Job summary

The University Hospitals Pain Management seeks a dedicated individual for a critical coordination role, ensuring optimal patient care through collaboration with healthcare teams. Key responsibilities include managing appeals and denials, while maintaining compliance with regulations and improvements in patient outcomes.

Qualifications

• Experience with healthcare regulations and compliance.
• Skills in coordinating with interdisciplinary teams.
• Knowledge of appeals and denial management processes.

Responsibilities

• Coordinate with healthcare teams for effective delivery of services.
• Perform appeals and denial communications.
• Support training to decrease denials.

Skills

Collaboration

Communication

Problem-Solving

Education

Bachelor's degree in Healthcare Administration or related field

Job description

DescriptionWhat You Will Do

• Collaborates and coordinates with all members of the health care team, patient and family (or significant others) to coordinate and ensure timely and efficient delivery of required workflow, services and tasks to result in:
  • Support of positive patient health care outcomes
  • Increased patient/health care team outcomes and satisfaction
  • Improved inpatient throughput and appropriate length of stay
  • Improved communication, awareness and adherence to regulatory requirements associated with utilization
  • Support for inappropriate level of care and decreased inpatient bed day denials
  • Continuity and coordination of care
  • Appropriate and timely authorization for level of care
  • Decreased denials
  • Appropriate reimbursement
• Perform timely and accurate review, denial communications and construct appeals, including remaining current with regulatory / payer and internal requirement.
• Collaborate with physicians, UM Nurses, PAS, and other members of the Interdisciplinary team and Revenue Cycle to collect all pertinent information to support successful appeals including communication of trends and appropriate escalation to ensure appropriate resolution resulting in expected payment.
• Document appeal activity according to department standards to support accurate and timely reporting of denial and appeal status, outstanding revenue and to help identify trends (payer, physician, service, DRG, reviewer). 20%
• Collaborate with supervisor to support training, and reinforcement resulting in decreased denials. 20%
• Conduct all UM activities with a focus on continuous quality improvement in a manner that is supportive of UHC quality initiatives and in compliance with applicable regulatory requirements

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.