Denials & Appeals MGR

1. Promotes a safe, cooperative and professional health care environment to ensure optimum patient care (as per HR Policy 113c).

2. Adheres to all hospital policies, procedures, rules and regulations, including but not limited to, absenteeism, ETIME, cellular telephone usage, dress code and rules of conduct.

3. Makes Customer Service a priority, treating customers (patients, visitors, and co-workers) in a professional manner exercising courtesy and tact. Effectively communicates with patients and others about SBH services in their area(s) of expertise or responsibility and ensures that concerns, questions or issues reach the right person(s) in SBH in a timely fashion.

4. Demonstrates the standards of performance and behaviors consistent with the DRIVE to Patient-Centered Excellence.

5. Concurrent Denials Management:

Evaluates denials received concurrently from payer for medical necessity. Notifies all members of the healthcare team, i.e. physicians, nurses, case managers, social workers, of the denial, and initiates concurrent appeal process , i.e. expedited appeal and/or peer to peer. Documents outcomes in the ACM. Assists with all possible medical and/or social delays in discharge.

Contacts managed care companies to communicate the clinical justification of the admission and/or continued stay.

6. Performs retrospective reviews as requested, including but not limited to short stays, Friday/weekend admissions and discharges.

7. Reviews concurrent denials, utilizing Interqual (CERMe) criteria, to ensure medical necessity. Coordinates and sets up concurrent / expedited appeal process as requested. Secures copies of the medical record as needed.

8. Reviews elective ambulatory surgery cases using the Interqual Inpatient Criteria to determine appropriateness of inpatient setting, and make recommendation as appropriate.

9. Prints and sends medical records of Addiction Medicine short stays that have not been reviewed, as requested by the behavioral review agencies.

10. Follows up appeal status and outcome of concurrent denials and peer to peer activities, and documents in appropriate software program.

11. Provides assistance to the social worker and case manager in obtaining authorizations from the managed care organization (that are delayed over 24 hours), for new placements, as directed.

12. Assists the Director of Case Management in the preparation of administrative reports (Emergency Department Case Management, Acute to Acute Transfers, etc)., and others as directed.

13. Assists in the completion of PRIs as requested, with maintenance of training and certification.

14. Performs retrospective appeals for At-Risk SBH Health First denials as required.

15. Information Management: Documents concurrent denials and appeals per department policy and maintains database to track denials and outcomes.

16. Maintains organized files of regulatory communications, denials, appeals, correspondence, medical records and supplemental documentation.

17. Maintains proficiency in the use of hospital and departmental applications: HBO, EMR, Interqual, CERMe, and ACM.

18. Documents follow up telephone calls and other communication per departmental policy. Organizes information making it readily available to others as appropriate, i.e: supervisor, analyst, administrative coordinators

19. Identifies problems early and effectively resolves them.

20 . Uses data effectively for planning and decision making.

21 . Methodically works toward departmental goals.

22. Performs other departmental tasks as requested and directed.

1. Education Required - Graduate from a recognized Nursing School or College. Evidence of continuing education courses, conferences or seminars. Bachelor's Degree preferred.

1. License(s) Required - Current New York State RN License

1. Experience / Skills Required - PRI certification within one year of hire.

3-5 years clinical nursing experience, preferably in an acute care hospital. Minimum of 2 years case management experience required. Denials and Appeals experience preferred. Managed Care experience is also preferred.