Denials Management Specialist, Registered Nurse (RN) License Required. Remote within Local Geogra...

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. 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. 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. EDUCATION: Graduate of an accredited professional nursing program.Registered nurse with current license to practice in the state of Pennsylvania or seek Pennsylvania licensure through reciprocity. Advanced degree preferred. 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 required.Prefer financial experience related to appeal processes with insurance providers.Demonstrated experience relating to all types of payers/providers. 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. Remote Skills: Acute Care, Apple Macs, Billing, Business Case, Case Management, Centers for Medicare and Medicaid Services (CMS), Clinical Nursing, Communication Skills, Corrective Action, Denials Management, Documentation, Financial Trend Analysis, Healthcare, Healthcare Providers, Identify Issues, Insurance, Managed Care, Medical Billing, Nursing, Nursing Credentials, Order Picking/Packing, Patient Care, Patient Care Denials, Process Flow, Registered Nurse (RN), Reporting Skills, Retro, Time Management, Utilization Management, Writing Skills About the Company: St. Luke's University Health Network St. Luke's University Health Network is a regional network of hospitals, physicians and other related organizations providing care primarily in Lehigh, Northampton, Monroe, Carbon, Schuylkill, Bucks, Montgomery and Berks counties in Pennsylvania and Warren County in New Jersey. The Network provides services at more than 150 sites. St. Luke's University Health Network is comprised of six hospital sites. The Network includes: • More than 80 owned physician-practice sites • 300 employed primary care/specialist physicians • Various outpatient testing and service facilities • Home health • Hospice services (inpatient and outpatient) • Largest ambulance provider in Bucks County and second largest in Lehigh County • Other related organizations • 57,500+ annual admissions • 195,000 annual emergency room visits • 1,325 physicians on the Medical Staff (96 percent board-certified) • 8,600+ employees • More than 1,350 volunteers Areas of exceptional medical expertise include: • Level 1 Adult Trauma Center: fully accredited by Pennsylvania Trauma Systems Foundation; 2,400+ annual trauma cases; St. Luke's 1.75 percent mortality rate represents top decile performance, significantly better than peer group as measured by National Trauma Data Bank of the American College of Surgeons; aeromedical transport services • Oncology: first and only cancer program in Pennsylvania to receive American College of Surgeons' highest quality recognition for three consecutive years; only Pennsylvania program to receive award in 2010; region's only fellowship-trained surgical oncologists; advanced programs for melanoma (internationally recognized melanoma investigator), lung, breast, prostate, gynecologic and gastrointestinal cancers and tumors of the brain and spine • Cardiology and Cardiovascular Surgery: multiple-year recipient of highest rating for cardiac bypass surgery, represents top decile performance achieved by only 10 percent of U.S. hospitals (Society for Thoracic Surgery); region's first Joint Commission certified Heart Failure Program; comprehensive surgical services excluding heart transplants • Neuroscience: accredited Stroke Center; additional Centers of Excellence include: Balance Center, Headache Center, Memory Disorders Center, Multiple Sclerosis Center, Sleep Disorders Center • Orthopaedics: advanced expertise in total joint replacement and reconstruction, computer-assisted minimally invasive surgery, primary and reconstructive surgery of the spine, sports injuries, diseases and conditions of the hand and elbow, traumatic injuries • Women's/Children's Health: high-risk pregnancy; the region’s busiest obstetrical service; two neonatal intensive care units; pediatric specialty care provided by St. Christopher's Hospital for Children. • Robotic/Minimally Invasive Surgery: one of the nation's most experienced robotic surgical teams • Radiology: designated international General Electric Healthcare Show Site for imaging technology; designated Breast Imaging Center of Excellence by American College of Radiology • Bariatric Surgery: designated Center of Excellence by American Society for Metabolic and Bariatric Surgery and Surgical Review Corporation St. Luke's offers an exceptional benefit plan for employees. Our values are reflected in all we do for patients, each other and the community: Pride - We take pride in our accomplishments and in our organization. Caring - We show consideration for others and their feelings. We treat others as we want to be treated. Respect - We recognize the value, diversity and importance of each other, those we serve and the organization. Accountability - We are responsible to make decisions and solve problems in a timely and effective manner. Flexibility - We adapt to the changing needs and expectations of those we serve. Teamwork - We work together to improve quality. The mission of St. Luke's University Health Network 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. Company Size: 5,000 to 9,999 employees Industry: Other/Not Classified Founded: 0 Apply tot his job