The Denials Case Manager, RN appeals all denials using InterQual criteria and medical necessity.  Collaboratively works with all members of the revenue cycle team and all types of payers to resolve denials, maximize accurate and timely reimbursement, and perform reimbursement recovery and retention service.  Evaluates, tracks and trends denials, and implements denial prevention programs.  Works in collaboration with Case Managers, Physicians, Finance and multidisciplinary teams to ensure compliance with documentation and educates as needed.

This position requires the full understanding and active participation in fulfilling the Mission of San Gabriel Valley Medical Center. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support San Gabriel Valley Medical Center’s strategic plan and the goals and direction of the Performance Improvement Plan (PIP).

According to the American Case Management Association Standard of Practice, Case Management is expected to “advocate for the patient while balancing the responsibility of stewardship for their organization, and in general, the judicious management of resources.”

Medicare defines Medical necessity as “health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.”

Specific Job Duties:

1. Ensures template for appeals includes reason for denial, diagnosis codes, MCG criteria used to support appeal, highlights of medical necessity supporting appeal, and only supporting documents necessary to support appeal are submitted with appeal template.
2. Has knowledge of appeal deadlines and ensures appeals are submitted within this timeframe. Tracks responses to appeals, follows-up as appropriate.
3. Working knowledge of levels of appeals, time lines, and contractual requirements related to appeals.
4. Works with payers to resolve issues related to underpayments or increased denial trends.
5. Ensures working knowledge of contracts to ensure appropriate reimbursement.
6. Works closely with facility department directors such as Admitting, Case Management, Patient Accounting and CBO Directors to review, resolve and streamline all necessary aspects of the appeals process
7. Establish appropriate tool for measuring Denial Tracking and Trending. Tracks and trends data, identifies opportunities for improvement, and establishes process improvement strategies as appropriate.
8. Works closely with Case Managers regarding the Peer to Peer process for concurrent denials. Ensures they are completed within timeframes and logged. Creates a peer to peer report on weekly/monthly basis for presentation at denials meetings.
9. May be asked to provide education and training to the Medical Staff, Nursing staff and or others related to denial prevention.
10. Leads in RAC preparedness and assists facility in the time of RAC Audits.
11. Participates in Continued Education in current laws that prevent unlawful denials, California Code of Regulations and HMO Compliance. Attends training and develops relevant knowledge and skills related to any identified gaps.
12. Participates in all Corporate and Facility based Denials Meeting
13. Participates in Utilization Management and other meetings regarding denials, and audits as necessary.
14. Other responsibilities deems necessary as delegated. regarding denials and denials prevention
15. Performs other duties as assigned.

Minimum Qualifications

• Graduate of an accredited RN School of Nursing
• BSN preferred
• Four years recent acute care experience in a critical care setting (preferred)
• Two years Utilization Management/Case Management experience
• Working knowledge of MCG, Intensity of Service/Severity of Illness criteria.
• Working knowledge of Title XXII and Title XIX.
• Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, Shared Risk, and Managed Care.
• Ability to negotiate with the physicians, payers, and customers.
• Ability to track outcomes and report findings.
• Able to problem solve effectively.
• Ability to use clinical knowledge to identify potential quality issues.
• Provides proper notification of absence or tardiness within established departmental time frames.

Licenses/Certifications

Current California RN License

Current BLS Card