RN Case Manager Appeals Specialist
Our client, a top recognized Healthcare Provider in the Chicagoland area, is looking for a RN Case Manager Appeals Specialist to become a solution for the denials process.
Position Summary: The Case Manager Appeals Specialist is responsible for ensuring that the organization receives appropriate payment for delivered services. The position is expected to review, research, and resolve
payment denials for all payers. The specialist is accountable for carrying out and documenting appeals,
adjudicating claims as appropriate, conducting formal account reviews, helping to identify root causes
of denials, and working with internal and external resources to resolve any root cause issues. Knowledge
of state/federal laws that relate to contracts and to the appeal process is vital.
Case Manager Appeals Specialist Position Responsibilities:
- Investigates and addresses denied accounts with the objective of appropriately maximizing reimbursement based upon services delivered and ensures that the claim is paid/ settled in a timely and accurate manner.
- Executes the denial appeals process, which includes receiving, assessing, researching, documenting, tracking, responding to, and/or resolving appeals with all payers.
- Tracks the status and progress of appeals and maintains well-organized records to ensure established timelines are met.
- Conducts internal and external correspondence accurately, clearly, concisely, and professionally while following organizational regulations.
- Oversees and assists clinical departments in correcting charge errors while advising departments on charging protocols; provides education to clinical departments on documentation requirements necessary to support charging activity.
- Using clinical and audit sills, conducts audits in response to payer inquires.
- Reviews patients’ charts and determines appropriate level of care. Reviews Local Coverage Determinations (LCD), National Coverage Determinations (NCD) and local clinical/medical policies to determine if services were medically necessary.
- Coordinates external audits/reviews and appeals with vendors.
- Reviews medical records retrospectively for audit/review accurately, objectively and independently.
- Collaborates with Patient Accounting Services and Managed Care Services in reviewing medical records regarding questions concerning patient types, level of care, and medical necessity.
- Applies knowledge of specific payer payment rules, managed care contracts, reimbursement schedules, eligible provider information and other available data and resources to conduct research on payment variances, make corrections, and take appropriate corrective actions to ensure resolution.
- Proactively follows-up on denied claims by contacting patients and payers, responding to their inquiries and supplying additional data as necessary.
- Complies with and maintains a working knowledge of applicable Federal, State, and local laws and regulations, Organizational Integrity Program and Standards of Conduct, and other policies and procedures in order to ensure adherence to an honest, ethical, and professional behavior.
- Has a solid working knowledge of the PFS, HIM and denials management systems and can report, analyze and share denials data to monitor and reduce denials.
- Collaborates with team members to continually improve services and engages in process and quality improvement activities.
- Collaborates with Inpatient Case Management Department to ensure patient type is correct.
- Collaborates with physicians and physician office staff when additional information is needed to submit an appeal and to provide information / education on payer medical policies to prevent future denials
- Required: Bachelors Degree
- Preferred: Masters Degree
- Required: 3-5 years of previous job-related experience
- Preferred: 6-10 years of previous job-related experience
- 2+ years of clinical nursing experience preferred
- Medical chart auditing experience required
- Experience as a Nurse Auditor or in a Case Management department preferred
- Required: Current Registered Nurse License State of Illinois
- Preferred: Specialty certification in clinical or functional area of nursing granted by a national nursing organization.
- Other: Case Management certification preferred.
- Required: Microsoft Excel Microsoft Power Point Microsoft Word
- Preferred: Access EPIC Other: Midas All Scripts (ECIN)