Registered Nurse (RN)-Denials And Appeal, FT, Dayss

Prisma Health; Greenville (SC); On-site; USD 85,000 - 110,000; Full time

Job summary

Prisma Health in Greenville, South Carolina is seeking an experienced registered nurse to coordinate and resolve clinical denials and appeals, while auditing revenue cycle processes and educating staff on reimbursement issues.

The role partners with Utilization Review and Outcomes Management, monitors payor trends, and produces tracking reports. A current RN license is required to practice in the state.

Qualifications

• Education - Associate degree in Nursing.
• Experience - Five (5) years Nursing experience in a hospital setting. Experience in in-patient, out-patient or physician coding experience, revenue cycle and/or utilization management experience preferred.
• Holds a current RN license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.

Responsibilities

• Coordinate and resolve denials and appeals for the system-wide revenue cycle.
• Collaborate with Utilization Review / Outcomes Management to resolve in-house denials and appeals.
• Monitor denial and appeals trends and report to management for process improvement.
• Produce denials and appeals tracking reports for Management and Departments.
• Provide comprehensive training on denial resolution and appeals processing to Prisma Health staff.
• Assist leadership with strategic goals to reduce denials volume.
• Maintain knowledge of current trends in healthcare related to denials and appeals.

Skills

Nursing experience

Coding experience

Revenue cycle

Utilization management

Education

Associate degree in Nursing

Job description

Inspire health. Serve with compassion. Be the difference.

Job Summary

Responsible for the coordination and resolution of the clinical observations inclusive of denials and appeals of the system-wide comprehensive. Performs the necessary audits to evaluate the revenue cycle process and educates staff on issues impacting reimbursement.

Essential Functions

• All team members are expected to be knowledgeable and compliant with Prisma Health’s purpose: Inspire health. Serve with compassion. Be the difference.

• Utilizing Prisma Health information systems, identifies and resolves accounts that have been improperly converted anddenied by insurance carriers for clinical reasons. This includes researching observations, denied claims, applying acuity criteria, collaborating with departments, confirmation of LOC’s processing and resolving the denial for appropriate payment.

• Facilitates the identification and resolution of in-house denials and appeals through effective collaboration with theUtilization Review / Outcomes Management department. Represents Prisma Health when interacting with payors in acuity and level of care issues.

• Monitors denial and appeals information for payor, provider or departmental trends. Routinely reports tomanagement regarding trends and recommends process improvement initiatives. Regularly reviews aging appeals and problem cases.

• Produces denials and appeals tracking reports for Management and Departments.

• Provides comprehensive training for Prisma Health staff regarding denial resolution, appeals processing, processimprovement and revenue cycle issues that impact reimbursement.

• Assists the Manager of Denials and Appeals Management and the Director of Reimbursement with the development of strategic goals relative to the reduction in denials volume.

• Maintains knowledge of current trends and developments in the healthcare industry and specifically as it relates to denials and appeals through appropriate literature and professional development activities.

• Performs other duties as assigned.

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• Education - Associate degree in Nursing

• Experience - Five (5) yearsNursing experience in a hospital setting. Experience in in-patient, out-patient or physician coding experience, revenue cycle and/or utilization management experience preferred

In Lieu Of

• NA

Required Certifications, Registrations, Licenses

• Holds a current RN compact/multistate license recognized by the NCSBN Compact State or is licensed to practice as an RN in the state the team member is working.

Knowledge, Skills and Abilities

• NA

Work Shift

Day (United States of America)

Location

Patewood Outpt Ctr/Med Offices

Facility

Corporate

Department

Patient Financial Services

Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.