Job description
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GENERAL SUMMARYWorks under the supervision of the Manager of Utilization Review Case Management. The Denial Case Manager's primary job function is to review denials, both inpatient and outpatient to screen for appropriateness of peer to peer, reconsideration/re-review, appeal, rebilling, and/or adjustment. Works with both SOMC and outsourced appeal staff for referrals. Manages accounts that have been finalized to assist with closing out accounts. Responsible for maintaining tracking system of worked denials. Manages assigned worklists, pulled from electronic health record. Assists appeal writers with follow-up on appealed accounts, as assigned. Expected to attend, discuss, and present denial trends and issues during Denial Team meetings. Tracks and works all CMS less than two-midnight accounts to ensure compliance with regulations. Works with multi-disciplinary team to assure appropriate documentation. Supports each Strategic Value by providing exceptional service. Supports each Strategic Value by providing exceptional service. Performs other duties as assigned.
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QUALIFICATIONS
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Education:
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Graduate of an accredited school of nursing required, or
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Graduate of an accredited school of practical nursing with 1 year of Interqual, MCG, or Case Management Experience required, or
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10 years of Case Management Hospital-based Insurance Review experience required
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Licensure:
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RN(OH) required, or as specified by health specialty (if applicable)
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Experience:
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Three years of progressively related experience preferred. Knowledge of advanced medical terminology and procedures, diagnosis, symptoms, disease processes treatments preferred. Case Management experience preferred.
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Interpersonal Skills:
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Ability to develop positive interactions with patients, families, physicians, and staff in order to effectively care for patients.
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Essential Technical/Motor Skills:
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Must have ability to use hands for repetitive simple grasping when writing, using computer, answering phone, copying and related office duties.
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Essential Physical Requirements:
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The physical demand level is light to medium. Occasionally may lift up to 15 pounds; stands and/or walks one to four hours per day; sits five to eight hours per day; occasional bending squatting, and reaching.
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Essential Mental Requirements:
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Has occasional contact with the general public and customer when performing all aspects of the job. Requires the ability to cope with deadlines, adjust to irregular activity schedules, concentrates, documents, prepares, and evaluate case management processes.
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Essential Sensory Requirements:
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Good vision is required to reviewing diagnostic data, and completing required documentation. The ability to communicate clearly is required to maintain effective contact with physicians and a variety of hospital personnel.
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Exposure to Hazards:
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Works in good physical surroundings. Occasionally exposed to dust, odor, body fluids, toxic substances, unpleasant patient care activities, and infectious diseases. Frequently exposed to noise.
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Other:
N/A
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JOB SPECIFIC DUTIES AND PERFORMANCE EXPECTATIONS
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Performs denial screening processes for inpatient and outpatient denials for the organization, utilizing policies, contracts, regulations, MCG and InterQual criteria.
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Sets up peer to peer reviews for providers and insurance companies; acts as a liaison for communication between the two.
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Works with other SOMC departments on adjustments and rebilling, as needed.
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Works with outsourced appeal companies.
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Assists with closing out finalized appeals, with both internal and outsourced staff.
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Manages tracking system of all denials worked.
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Manages assigned worklists, pulled from the electronic health record.
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Follows up on appealed accounts for appeal writers, as assigned.
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Serves as a member of the denial team; attends scheduled meetings and is prepared to discuss and present on denial topics.
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Manages all CMS two-midnight accounts; responsible for the tracking system and ensuring compliance with regulations.
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Assists with documentation improvement, to decrease future denials.
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Performs other duties as assigned.
The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.
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Location: Southern Ohio Medical Center ยท Utilization Review
Schedule: Full-Time, Days, 100% Remote
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