Health Care Specialist, RN

3 weeks ago

Allentown, United States St. Luke's University Health Network Full time


St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.

The Denials Management Specialist reviews inpatient CMS and third party denials for medical necessity and tracks outcomes regarding appeal process. Assists billing staff regarding outpatient denials for experimental, coding or other issues that may require record review. Provides billing with information needed to obtain payment of claims.

Remote within local geography after orientation.

JOB DUTIES AND RESPONSIBILITIES:

  • Reviews all Inpatient Retroactive Denials in the Denials Management Work Queues for Medical Necessity and Late-Pick-Up/Notification that are entered by Case Management and Business Office.
  • Monitors retro denials to ensure resolution within required time frames and logging of action e.g. no appeal, appeal level and final decision with revenue impact.
  • Assists Case Management as necessary to ensure that documentation is entered and transmitted to insurance carriers within acceptable timeframes to comply with appeal deadlines.
  • Provides feedback to Case Management that can help in preventing future denials and assists in maintaining good communication and process flow between the 2 departments.
  • Responsible for writing appeal letters for Inpatient CMS and Commercial late pick-ups, medical necessity, and other requested denials as deemed clinically appropriate.
  • Investigates managed care and commercial insurance rejections, denials for possible experimental services and coding issues, providing supplemental information to resolve claim.
  • Identifies operational issues that contribute to denials and rejections.
  • Works with departments and providers to implement corrective actions to minimize lost revenue due to denials and rejections.
  • Assists in preparing reports regarding denials to include volumes, number of appeals, case resolution, and impact on revenue and trending.
  • Coordinates RAC appeals for complex case reviews for medical necessity, including determining if appeal is appropriate and communicating with vendor to ensure timely filing of same. Performs writing of RAC/MAC appeals at appropriate levels and documenting status.

EDUCATION REQUIREMENT:

  • Must be a graduate of an accredited, professional nursing program. 
  • Must have current RN license to practice in the state of Pennsylvania or seeking Pennsylvania license through reciprocity.

PHYSICAL AND SENSORY REQUIREMENTS:

Requires sitting for up to 4 hours per day, 2 hours at a time. Standing for up to 4 hours per day, 3 hours at a time. Requires occasional fingering, handling and twisting and turning. Occasionally requires reaching above shoulder level. Must have the ability to hear as it relates to normal conversation, seeing as it relates to general, peripheral and near vision, visual monotony.

TRAINING AND EXPERIENCE:

  • Minimum of 2-5 years of clinical nursing experience in an acute care hospital setting required.
  • Prefer minimum of 2-5 years’ experience in case management and/or utilization management.
  • Prefer financial experience related to appeal processes with insurance providers. 
  • Demonstrated experience relating to all types of payers/providers. 

LOCATION:

Remote within local geography after orientation for approximately 6-8 weeks at St. Luke's Center, Allentown, PA.

Please complete your application using your full legal name and current home address.  Be sure to include employment history for the past seven (7) years, including your present employer.  Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable.  It is highly recommended that you create a profile at the conclusion of submitting your first application.  Thank you for your interest in St. Luke's



St. Luke's University Health Network is an Equal Opportunity Employer.

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