Job Summary

Under the general supervision of the Care Management Leadership, the Clinical Denial Supervisor performs advanced level work related to clinical denial management. The individual is responsible for managing medical denials for hospital care by conducting a comprehensive review of clinical documentation. The Clinical Denial Supervisor will write compelling arguments based on the clinical documentation and the medical policies of the payer and submit the appeal in a timely manner. The Clinical Denial Supervisor will also handle audit-related / compliance responsibilities and other administrative duties as required.

The position identifies and works to resolve problems to ensure accurate and complete billing, and works with the care management leadership and physician advisors to educate staff on follow-up and documentation practices. The position reviews third party payer reimbursement denials for hospital services based on the following: documentation, medical necessity, and related issues. Using data from these reviews, the Clinical Denial Specialist will work with care management staff to identify and rectify documentation errors. Additionally, this position will actively manage, maintain and communicate denial / appeal activity to appropriate stakeholders and report suspected or emerging trends related to payer denials to Revenue Cycle management.

This position anticipates and responds to a wide variety of issues/concerns. The position works independently to plan, schedule and organize activities that directly impacts hospital and physician reimbursement. This role is key to securing reimbursement and minimizing organizational write offs.

This position represents Care New England, the Care Management team at Women and Infants Hospital, and the Revenue Cycle team by adhering and upholding the Mission, Vision, and Values, and Service Performance Standards in providing the highest quality service. They will support their co-workers, engage in positive interactions, and provide helpful assistance in anticipating and responding to the needs of our customers.

Duties & Responsibilities

1. Research clinical denials related to referral, medical necessity, case management, non-covered services, resulting in denials and delays in payment. Initiate appeals with insurers appropriately. Other types of denials may be requested for the specialist to research, review and appeal through the care management leadership.
2. Submit detailed, customized appeals to payers based on review of medical records and in accordance with Medicare, Medicaid, and third-party guidelines as well as CNE policies and procedures
3. Initiate Peer to Peer reviews as appropriate and communicate thoroughly and accurately with payers and Peer Review organizations to resolve denials
4. Monitor and follows up on appeals throughout entire process
5. Maintains accurate, clear, timely documentation related to denied cases
6. Develops, implements, and evaluates processes to ensure accurate and timely collection of information.
7. Serve as a resource for hospital case management departments regarding concurrent denials
8. Assist the Care Management department on implementing a strong process that will help prevent claims denials and lodge successful requests for appeals
9. Works with and educates staff, physicians, and payers on reimbursement issues, clinical protocols/criteria, insurance plan changes, regulations and process improvements.
10. Coordinate appropriate status determinations using InterQual and Medicare guidelines
11. Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution
12. Tabulates the financial gains of the position and opportunities for improvement
13. Review payer communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate
14. Submits retro-authorizations in accordance with payer requirements in response to authorization denials
15. Assist with clinical support for complex, specialized billing and follow-up workflows including but not limited to:
    1. RAC correspondence and appeal processing, as well as other audit reviews
    2. Advanced billing procedures requiring extensive communication with other departments
    3. Consecutive account processing and Medicare A/B split claims processing
16. Supports director in other related responsibilities as requested
17. Responds to patient and family inquiries regarding denials
18. Serves as a resource, maintains expertise and continues self-education by attending applicable conferences, workshops and interdisciplinary meetings.
19. Utilizes local, regional and national forums to continuously enhance expertise and knowledge base.
20. Participates in applicable professional organizations and committees.

Requirements

• Bachelor's degree in nursing preferred and a minimum of 2 years job-related experience or equivalent is required.
• RI State Nursing Licensure is also required.
• Experience must include graduation from an accredited nursing program.
• Two years recent experience in hospital case management with demonstrated competency in InterQual and/or MCG and Medicare rules and regulations.
• Knowledge of and comfort with EMR functionality required.
• Previous management of clinical appeals preferred.
• Certification in Care Management, CCM or ACM required. Upon hire will obtain Certification in Care Management within two years of hire if not already in place.