Johns Hopkins Health System employs more than 20,000 people annually. Upon joining Johns Hopkins Health System, you become part of a diverse organization dedicated to its patients, their families, and the community we serve, as well as to our employees. Career opportunities are available in academic and community hospital settings, home care services, physician practices, international affiliate locations and in the health insurance industry. If you share in our vision, mission and values and also have exceptional customer service and technical skills, we invite you to join those who are leaders and innovators in the healthcare field.
Under general supervision of the Director, Revenue Cycle Management and/or Revenue Cycle Manager, Appeals and Denials, the Senior Charge Defense Nurse Specialist performs activities to ensure appropriate financial remuneration for inpatient services from third party payers. The position provides a vital link between Patient Accounting, Utilization Management, and Insurance Companies. The individual will be responsible for tracking denied inpatient claims, work with the Appeals Specialist, the Office of Managed Care, payers, outside law firms, and other sources to overturn denials on appeal and be an integral part of the effort to obtain payment for services.
Critical to this position is the ability to multitask. The individual must have organizational and analytical skills. The individual must have the ability to analyze and trend data to identify sources of payment denials and identify ways to improve internal processes to reduce denials. The Senior Charge Defense Nurse Specialist must be able to work with the Appeals Coordinators, Utilization Management, department administrators, and various billing areas to design processes to minimize denials, to appeal denied claims and track success of both efforts. The Senior Charge Defense Nurse Specialist must be able to compile reports as needed to track appeal results.
The Senior Charge Defense Nurse Specialist works as team member and positively accepts change throughout the Health System while establishing relationships at all facilities and be familiar with each institution’s computer environment and payer contracts as needed.
- Baccalaureate degree, or associate degree, or diploma in nursing from an accredited School of Nursing.
- Requires detailed working knowledge of medical terminology, anatomy and physiology, surgical procedures and basic disease processes.
- Requires working knowledge of clinical pathways, disease state management and utilization review criteria
- Requires detailed knowledge of current regulatory requirements and legislation for a variety of third party payers.
- Requires knowledge of healthcare accounts receivable management concepts, including familiarity with the Maryland and regulatory environment to ensure compliance with State regulations regarding patient and insurance billing issues.
- Requires knowledge of all JHHS specific contractual agreements to ensure compliance and timing for the audit process.
- Requires detailed knowledge of the claims and settlement process and utilization management for MCO/HMO or other third-party payers.
- Requires detailed working knowledge of the JHHS revenue cycle to understand charging and coding structures.
- Requires knowledge of multiple JHHS data base systems, scheduling, registration, billing applications, and reporting mechanisms.
- Requires knowledge of Microsoft Office Suite.
- Requires knowledge of accounting and receivables management principles.
- Requires proven analytical ability and organizational skills necessary to review patient medical records with third-party payers analyze and trend data and provide recommendations based on data analysis.
- Requires the ability to explain clinical treatment plans as well as JHHS admission policies and procedures to various internal and external constituencies.
- Must possess excellent verbal and written communication skills to support interactions and participation in meetings with third-party payers, physicians, clinicians, and other representatives within the organization (Registration, Legal, JHMCIS, Medical Records, Utilization Management, etc.).
- Knowledge of and experience with EPIC preferred.
Requires Licensure, Certification, Etc.:
- Registered Nurse licensed in the state of Maryland
- Five or more years related experience in health care, health insurance industry, healthcare billing, or Nursing experience in acute care setting.
- Demonstrated proficiency in developing and utilizing spreadsheets, graphics and word processing.
- A minimum of four years of experience in nursing in an acute care setting.
- A minimum of two years charge audit experience.
- Schedules audit as requested by payer following advance payment and review of contractual arrangements and requirements.
- Obtains patient medical record and coordinates audit with third party payer. Serves as liaison during on-site audit.
- Contacts ancillary departments to investigate documented procedures versus actual charges processed and billed.
- Analyzes clinical and financial information of random patient accounts to ensure integrity of billed claim and to ensure maximization of reimbursement. Completes targeted audit of known ancillary department issues.
- Completes supporting correspondence and obtains appropriate documentation to effectively process audits.
- Provides feedback to appropriate areas concerning audit results and develops action plans to prevent future audit issues. Prioritizes issues and determines process improvements to maximize reimbursement.
- Administers quality-monitoring program to identify training needs and/or improvement opportunities. Completes exit interviews with all payers.
- Monitors under/over-charging from audits and determines trends in targeted areas. Challenges third-party payer audit practices.
- Develops and implements database detailing audit cases, statuses, decisions, and historical outcomes.
- Develops and delivers concise monthly management reports, which summarize audit case status, trends and quality assurance issues.
- Provides daily feedback reporting of Ancillary Departments and Physician documentation issues that impact the timeliness of reimbursement or that impact data element quality or integrity.