Denial Specialist
St. Johns Riverside Hospital, Yonkers, NY, United States
Denial Specialist
The Denial Specialist is a Registered Professional Nurse or a Licensed Social Worker responsible and accountable for the review and appeal of clinical denials to the Insurance Companies and the review of clinical documentation to assure it meets hospital requirements. This position would also be responsible for working with the Case Manager on admission to ensure that the authorization for inpatient hospitalization is obtained. Reviews inpatient medical records for identified payer population (Medicare, Medicaid, and Blue Cross/Blue Shield) as directed on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation. Able to create and work with Excel Spreadsheets for monthly key metrics on denials. Consults and collaborates with the finance department to coordinate and maximize the efficiency and coordination of appeals. Promotes customer satisfaction and works with Commercial Insurance companies as well as CMS to ensure that we are sending out information timely. Demonstrates awareness of nursing skills, Milliman Clinical Review criteria, NYS LOCADTR, and CMS guidelines and regulations regarding appeals for authorization, medical necessity, and continued stay denials Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation. Works closely with Case Management and Clinical Documentation teams to assure documentation of discharge diagnosis(es) and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care. Demonstrates basic knowledge about HIS standards of coding and applies to ongoing evaluation of medical record documentation. Consistently meets established productivity targets for record review. Demonstrates knowledge of nursing theory, practice, and leadership ability. Plans, organizes, coordinates, and evaluates the quality of clinical documentation and works collaboratively with Medical and Hospital staff to assure compliance. Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation. Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps identify problems, offers solutions, and participates in their resolution. Maintains the confidentiality of information acquired pertaining to patient, physicians, associates and visitors to hospital. Discusses patient and hospital information only among appropriate personnel in appropriately private places. Behaves in accordance with the Mission, Vision and Values of the hospital. Assumes responsibility for performance of job duties in the safest possible manner, to assume personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management. Promotes the standards of care and service excellence according to Hospital philosophy and goals and/or unit guidelines. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care, considering age specific, development, cultural and spiritual needs of the patient. Qualifications
Licensed and Currently registered LCSW under the laws of the State New York or Licensed and currently Registered Nurse under the laws of the State New York. BSN degree required; MSN and professional certification preferred. Minimum of five (3) years experience in adult inpatient medical/surgical or critical care or case management/ denials experience. Possesses well-developed and effective interpersonal skills and is able to communicate effectively verbally and in writing to influence physician documentation processes. Demonstrates nursing skill competencies and critical thinking. Possesses analytic skills necessary to clinically assess medical records. Demonstrates confidence in actions and exercises good judgment. Demonstrates competency skills in word processing and spread sheets utilization. Displays leadership ability and the willingness to assume authority and accountability for role functions. Possesses the ability to plan, organize, develop and implement goals, objectives, policies and procedures necessary for quality care. Demonstrates ability to recognize problems, approach them in an objective manner, reach appropriate solutions, implement them and evaluate for effectiveness. Embraces and adapts to change.
The Denial Specialist is a Registered Professional Nurse or a Licensed Social Worker responsible and accountable for the review and appeal of clinical denials to the Insurance Companies and the review of clinical documentation to assure it meets hospital requirements. This position would also be responsible for working with the Case Manager on admission to ensure that the authorization for inpatient hospitalization is obtained. Reviews inpatient medical records for identified payer population (Medicare, Medicaid, and Blue Cross/Blue Shield) as directed on admission and throughout hospitalization. Analyzes clinical status of patient, current treatment plan and past medical history and identifies potential gaps in physician documentation. Able to create and work with Excel Spreadsheets for monthly key metrics on denials. Consults and collaborates with the finance department to coordinate and maximize the efficiency and coordination of appeals. Promotes customer satisfaction and works with Commercial Insurance companies as well as CMS to ensure that we are sending out information timely. Demonstrates awareness of nursing skills, Milliman Clinical Review criteria, NYS LOCADTR, and CMS guidelines and regulations regarding appeals for authorization, medical necessity, and continued stay denials Communicates with attending physician either verbally or through written methodology to validate observations and suggest additional and/or more specific documentation. Works closely with Case Management and Clinical Documentation teams to assure documentation of discharge diagnosis(es) and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care. Demonstrates basic knowledge about HIS standards of coding and applies to ongoing evaluation of medical record documentation. Consistently meets established productivity targets for record review. Demonstrates knowledge of nursing theory, practice, and leadership ability. Plans, organizes, coordinates, and evaluates the quality of clinical documentation and works collaboratively with Medical and Hospital staff to assure compliance. Identifies strategies for sustained work process changes that facilitate complete, accurate clinical documentation. Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps identify problems, offers solutions, and participates in their resolution. Maintains the confidentiality of information acquired pertaining to patient, physicians, associates and visitors to hospital. Discusses patient and hospital information only among appropriate personnel in appropriately private places. Behaves in accordance with the Mission, Vision and Values of the hospital. Assumes responsibility for performance of job duties in the safest possible manner, to assume personal safety and that of co-workers, and to report all preventable hazards and unsafe practices immediately to management. Promotes the standards of care and service excellence according to Hospital philosophy and goals and/or unit guidelines. Acts as a resource person for the interdisciplinary team in order to promote collaboration and coordination of patient care, considering age specific, development, cultural and spiritual needs of the patient. Qualifications
Licensed and Currently registered LCSW under the laws of the State New York or Licensed and currently Registered Nurse under the laws of the State New York. BSN degree required; MSN and professional certification preferred. Minimum of five (3) years experience in adult inpatient medical/surgical or critical care or case management/ denials experience. Possesses well-developed and effective interpersonal skills and is able to communicate effectively verbally and in writing to influence physician documentation processes. Demonstrates nursing skill competencies and critical thinking. Possesses analytic skills necessary to clinically assess medical records. Demonstrates confidence in actions and exercises good judgment. Demonstrates competency skills in word processing and spread sheets utilization. Displays leadership ability and the willingness to assume authority and accountability for role functions. Possesses the ability to plan, organize, develop and implement goals, objectives, policies and procedures necessary for quality care. Demonstrates ability to recognize problems, approach them in an objective manner, reach appropriate solutions, implement them and evaluate for effectiveness. Embraces and adapts to change.