Supports the revenue cycle by completing retrospective reviews to ensure medical necessity criteria is met. Assures enterprise activities conform to regulatory requirements and identifies trends, process opportunities to maximize reimbursement. Supports policy development and interdisciplinary education.
Due to the changing landscape in healthcare it is becoming more and more challenging to receive payments for the quality care that Cleveland clinic provides.
Payers often deny for administrative misses and require Cleveland Clinic to file appeals.
Cleveland Clinic is seeking motivated and eager Nurses to join our Payer Denial Management Team. Our team offers flexible start times and the opportunity to work from home after a successful new hire period.
- Payer Denial Management Nurse: Supports the denial and appeal process within the Payer Denial Management department. Coordinates denial appeal follow-up and analyzes provided clinical documentation, criteria application, physician advisor input, completes review of the medical record and formulates the appeal letter. Participates in the application of medical necessity review and utilizes criteria tool (MCG and/or InterQual). Ensures compliance standards are met with required elements and provides feedback to the management team. Relays physician, nursing and care manager documentation improvement opportunities to assist with appeal defense process.
- RAC /Payer AuditNurse: Supports denials, appeals, within the Payer Audit department. Conducts audit reviews to assure activities conform to regulatory requirements. Coordinates denial appeal follow-up; analyzes provided clinical documentation, criteria application outcome, physician advisor input, completes review of the medical record and formulates the appeal letter. Expert in the application of medical necessity review criteria tool (MCG and/or InterQual). Supports the development of performance improvement strategies in response to identified patterns and trends involving government payers.
- Charge Capture Nurse: Supports the Observation charge capture process for the enterprise. Works with a multi-disciplinary team to evaluate and improve the charge capture process. Reviews the medical record for Observation cases to ensure accurate and timely billing of observation hours and appropriate charges. Utilizes the application of medical necessity review criteria tool (MCG and/or InterQual). Works cooperatively to review, evaluate and improve the charge capture process to establish an enterprise uniform process. Supports development of performance improvement strategies in response to identified patterns and trends.
- Other duties as assigned.
- Bachelor of Science in Nursing or Bachelor's degree in a related field preferred.
- Licensed Registered Nurse (RN) in the state of Ohio, BSN preferred.
- Professional certification as a Case Manager preferred.
- Expertise with InterQual and Milliman disease management ideologies preferred.
Complexity of Work:
- Requires critical thinking skills, decisive judgment and the ability to work with minimal supervision.
- Must be able to work in a stressful environment and take appropriate action.
- Minimum 3-5 years Care Management or Utilizationexperience which would include acute med/surg experiencerequired.
- Expertise with InterQual and Milliman disease management ideologies is preferred.
- In-depth familiarity with third party billing requirement and regulations, billing documentation requirements preferred. Understanding of CPT and HCPCS coding guidelines preferred.
- Manual dexterity to operate office equipment.
- Requires extended periods of standing, walking, sitting and carrying up to 25 pounds.
- Normal or corrected vision and hearing to normal range.
Personal Protective Equipment:
- Follows standard precautions using personal protective equipment as required.
Keywords: Nurse Case Manager, RN Case Manager, Payer denial case manager, flexible start time.