Denials Management Specialist, Registered Nurse (RN) License Required
St. Luke's University Health Network
full-time
Posted on:
Location Type: Hybrid
Location: Allentown • New Jersey, Pennsylvania • 🇺🇸 United States
Visit company websiteJob Level
JuniorMid-Level
About the role
- Reviews inpatient CMS and third party denials for medical necessity and tracks outcomes regarding appeal process.
- Assists billing staff regarding outpatient denials for experimental, coding or other issues that may require record review.
- Provides billing with information needed to obtain payment of claims.
- Monitors retro denials to ensure resolution within required time frames and logging of action e.g. no appeal, appeal level and final decision with revenue impact.
- Provides feedback to Case Management that can help in preventing future denials and assists in maintaining good communication and process flow between the 2 departments.
- Responsible for writing appeal letters for Inpatient CMS and Commercial late pick-ups, medical necessity, and other requested denials as deemed clinically appropriate.
- Investigates managed care and commercial insurance rejections, denials for possible experimental services and coding issues, providing supplemental information to resolve claim.
- Identifies operational issues that contribute to denials and rejections.
- Works with departments and providers to implement corrective actions to minimize lost revenue due to denials and rejections.
- Assists in preparing reports regarding denials to include volumes, number of appeals, case resolution, and impact on revenue and trending.
Requirements
- Registered nurse with current license to practice in the state of Pennsylvania or seek Pennsylvania licensure through reciprocity.
- Graduate of an accredited professional nursing program.
- Minimum of 2-5 years of clinical nursing experience in an acute care hospital setting required.
- Prefer minimum of 2-5 years’ experience in case management and/or utilization management required.
- Prefer financial experience related to appeal processes with insurance providers.
- Demonstrated experience relating to all types of payers/providers.
Benefits
- St. Luke's is proud of the skills, experience and compassion of its employees.
- The employees of St. Luke's are our most valuable asset!
- Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
medical necessity reviewappeal process managementbilling assistancedenial investigationreport preparationcoding issue resolutionoperational issue identificationrevenue impact analysiscase resolution trackingclinical nursing experience
Soft skills
communicationcollaborationproblem-solvingfeedback provisionorganizational skillsattention to detailinterpersonal skillsprocess improvementanalytical thinkingtime management
Certifications
Registered Nurse licenseaccredited nursing program graduation