RN Denials & Appeals Case Manager

Stony Brook University; Setauket (NY); On-site; USD 90,000 - 128,000; Full time

Job summary

Stony Brook University Hospital is seeking a Denials and Appeals Case Manager to perform quality retrospective chart reviews for potential appeals of denied days across payers, including government programs.

The role collaborates with financial services to capture correct reimbursements, maintains data on denial activity, and educates staff on denials; requires NY RN licensure and 5 years in acute care hospital, with strong writing and IT skills, and availability on weekdays and weekends.

Qualifications

• RN Licensure NY State.
• Bachelor's Degree or enrolled.
• Five years’ experience in Acute Care Hospital.
• Good writing skills and computer efficient.
• Experience in CM, Quality or UM.
• Working knowledge of MCG and/or Interqual.
• Excellent communication and interpersonal skills.
• High level customer service.
• Creativity, flexibility, professional and courteous.
• Weekday and Weekend flexibility.
• Work independently.

Responsibilities

• Provide Utilization Reviews for Short Stay and Observation.
• Conduct retrospective review for potential appeal of all denied cases.
• Participates proactively and collaboratively to enhance reimbursements and reduce denials.
• Collects and maintains data to identify and analyze patterns, trends and solutions with reports on all denial activity.
• Documents avoidable delays and admissions.
• Promotes continuous quality improvement and efficient use of hospital resources.
• Collaborates with the interdisciplinary team on all complex cases. Maintains high level of customer service at all times.
• Review retrospective denials for managed care, Medicare and Medicaid.
• Present and educate staff on denials.

Education

NY RN Licensure

Bachelor's degree or enrolled

Tools

MCG

Interqual

Word

Excel

Access

Job description

Stony Brook University Hospital is seeking a Denials and Appeals Case Manager to perform quality retrospective chart reviews for potential appeals of denied days across payers, including government programs.

The role collaborates with financial services to capture correct reimbursements, maintains data on denial activity, and educates staff on denials; requires NY RN licensure and 5 years in acute care hospital, with strong writing and IT skills, and availability on weekdays and weekends.