Position Summary

The purpose of this position is to provide quality retrospective chart reviews for potential appeal of denied days for all payers including government and external denials. Staff track and trend denial activity and work with financial services to capture correct reimbursement for all these cases. Qualified candidates will demonstrate superior patient care and possess outstanding communication skills while adhering to our high standard of excellence.

The duties of a Denials / Appeals RN Case Manager may include the following but are not limited to:

• Provide Utilization Reviews for Short Stay and Observation
• Conduct retrospective review for potential appeal of all denied cases.
• Participates proactively and collaboratively to enhance reimbursements and reduce denials.
• Collects and maintains data to identify and analyze patterns, trends and solutions with reports on all denial activity.
• Documents avoidable delays and admissions
• Promotes continuous quality improvement and efficient use of hospital resources.
• Collaborates with the interdisciplinary team on all complex cases. Maintains high level of customer service at all times.
• Review retrospective denials for managed care, Medicare and Medicaid
• Present and educate staff on denials

Qualifications

Required:

• RN Licensure NY State.
• Bachelor's Degree or enrolled.
• Five years' experience in Acute Care Hospital.
• Good writing skills and computer efficient.
• Experience in CM, Quality or UM.
• Working knowledge of MCG and/or Interqual.
• Excellent communication and interpersonal skills.
• High level customer service.
• Creativity, flexibility, professional and courteous.
• Weekday and Weekend flexibility.
• Work independently.

Preferred:

• Certification in CM, UM, Quality, MCG.
• PRI Certified.
• Master's Degree.
• Previous experience with appeal/denial writing.
• Proficient in Word, Excel and Access.
• Recent experience in tertiary care.
• Knowledge of regulatory requirements.
• Experience in psychiatry or pediatrics.
• Leadership skills, coding experience.
• Bilingual

Please Note: Verification of degree (e.g., diploma or official transcript) is required for this role. Upload of documentation must be included with your application for consideration.

Special Notes: Resume/CV should be included with the online application.

Posting Overview: This position will remain posted until filled or for a maximum of 90 days. An initial review of all applicants will occur two weeks from the posting date. Candidates are advised on the application that for full consideration, applications must be received before the initial review date (which is within two weeks of the posting date).

If within the initial review no candidate was selected to fill the position posted, additional applications will be considered for the posted position; however, the posting will close once a finalist is identified, and at minimal, two weeks after the initial posting date. Please note, that if no candidate were identified and hired within 90 days from initial posting, the posting would close for review, and possibly reposted at a later date.

• Stony Brook Medicine is a smoke free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.
• All Hospital positions maybe subject to changes in pass days and shifts as necessary.
• This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.
• This function/position maybe designated as "essential." This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities.

Prior to start date, the selected candidate must meet the following requirements:

• Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services*
• Complete electronic reference check with a minimum of three (3) professional references.
• Successfully complete a 4 panel drug screen*
• Meet Regulatory Requirements for pre employment screenings.
• Provide a copy of any required New York State license(s)/certificate(s).

Failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.

*The hiring department will be responsible for any fee incurred for examination.

Anticipated Pay Range:

The salary range (or hiring range) for this position is $89,760 - $127,975 Base

The above salary range represents SBUH's good faith and reasonable estimate of the range of possible compensation at the time of posting. The specific salary offer will be based on the candidate's validated years of comparable experience. Any efforts to inflate or misrepresent experience are grounds for disqualification from the application process or termination of employment if hired.

Some positions offer annual supplemental pay such as:

• Location pay for UUP, CSEA & PEF full-time positions ($4000)

Your total compensation goes beyond the number in your paycheck. SBUH provides generous leave, health plans, and a state pension that add to your bottom line.