RN Specialist Denials & Appeals

Responsibilities:

• Uses clinical and coding knowledge to ensure accurate and compliant charge items and to recognize and resolve billing inconsistencies.

• Reviews commercial and government claim denials and audit requests and coordinates attempts to overturn denials by drafting appeals, negotiating with payers, or following up with payer utilization review departments in attempts of obtaining authorizations and claim payment.

• Establishes and maintains positive and cooperative relationships with medical staff and care coordination leaders to ensure ongoing compliance with utilization review guidelines.

• Collaborates with managed care department to code billable items for reimbursement. Collaborates with appropriate staff to secure information for billable items.

• Analyzes and creates reports to capture payer denial trends and volume, to support patient financial services and clinical leaders in the revenue cycle. 

• Coordinates projects and audits to improve processes related to revenue cycle, efficiency of charging and billing, and collection efforts.

• May educate case management staff and other departments regarding payer changes and denial/appeal process.

Education: 
•  Diploma from an accredited school/college of nursing required. 

Licensure / Certification / Registration: 

 Required Credential(s): 
• Registered Nurse credentialed from the New York Board of Nursing. 

Complexity of Work:
• Within scope of job, requires critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment.

Personal Protective Equipment:
• Follows Standard Precautions using personal protective equipment as required. Must be able to speak, read, write and follow instructions in English.