Department Description: Integrated Care Partners (ICP) is a physician-led, clinically integrated health care network whose mission is to assist our members in providing the highest quality care at the most reasonable cost for our patients in the current, rapidly changing medical environment.
Position Summary: The Denial and Appeals Nurse is an integral part of the Care Management team. Their focus is on the management of the payer denial and appeals process. The Denial and Appeals Nurse is responsible for appealing inappropriate denials through all levels of the appeals process. The Denial and Appeals Nurse is able to work autonomously and swiftly, managing a high volume of complex cases across all HHC system hospitals.
Key Areas of Responsibilities: - Follow standard work processes to manage denials and appeals
- Ensure activities are completed within regulatory and payer timeframes
- Develop and maintain collaborative relationships with internal and external stakeholders as needed to obtain additional information to properly formulate the clinical appeal and to resolve any issues that may arise during the appeals process
- Partner with the Medical Director and Physician Advisor staff to compose factually sound appeal letters for denial reconsiderations utilizing clinical documentation and contract language
- Maintain all documentation associated with the processing and handling of appeals to comply with regulatory standards and timeframes while maintaining an accurate, complete appeals record in the appropriate database
- Assist in analysis and documentation of root cause for denials
- Provide education to stakeholder groups on findings, analysis and mitigation strategies as needed
- Work with multi-disciplinary team to identify denial / appeal trends and supports development of performance improvement strategies in response to identified patterns
- Other duties as assigned.
Reports To: Manager, Clinical Resource Management
Qualifications: Education: Registered Nurse. Bachelors of Science in Nursing is preferred.
Experience: Five years of relevant case management, utilization management or managed care experience.Thorough understanding of Medicare, Medicaid, and Commercial reimbursement methodologies is preferred.
Licensure, Certification, Registration: Current State of Connecticut RN license is required. CCM (certified case manager), CPUM (certified professional in utilization management), or other relevant certification is preferred.
Knowledge, Skills and Ability Requirements: - Strong interpersonal and written / oral communication skills
- Maintains a positive attitude in a fast-paced environment
- Able to influence and negotiate
- Critical thinking, astute assessment and confident in decision making
- Knowledge of Interqual, MCG, or equivalent criteria and reimbursement guidelines
- CT RN license required without restriction, to the extent allowed by State and Federal law.
- Use of Microsoft Office including Word, Excel, and Power Point
- Use of EPIC
