DENIAL MGMT COORD

The Denials Management Coordinator serves as a daily liaison between case management, medical records, billing, medical staff, etc. relating to revenue recovery. Major Position Responsibilities: Performs retrospective medical record chart review on recent discharges and provide clinical medical necessity reviews to ensure timely reimbursement. The RN in this position will manage denied cases in a timely manner and possess a sense of urgency to turn around cases based on the rules and guidelines set by each payer. The Denial Manager will seek guidance of the Medical Director of Utilization Management for medical necessity review and final approval of all correspondence written to the insurance companies. Reviews medical claims that have been denied by payers (Medicare, private insurances, Medicaid, etc.) Identify medical necessity and defend the reasons why a patient met the appropriate level of care to capture loss revenue. Coordinates and gathers the data to send to denial sources in a pre-established limited time frame. Required to write appeal letters. Must meet Appeals deadlines as set by Statute & Contractual agreements. Collaborates with physician(s), physician's office staff, registration staff, and Patient Finances Services to obtain the necessary information to support medical necessity to avoid and or to reverse potential denials. Works with - Business office, Patient Finance Service , and HIM departments to coordinate and ensure that the requirements are met for the Centers for Medicare & Medicaid Services, such as Recovery Audit Contractors, Medicare's MAC, private insurances, and other governmental entities . Functions as a resource person to various departments involved in the review process. Utilizes written criteria, standards, local and national coverage of determination and norms and then apply professional knowledge and clinical expertise/competence in evaluating the Medical Record and documents for appropriateness of level of care for patients' hospitalization (Inpatient vs. Observation). Supports the Utilization Review function of the hospital- by working closely with the Physician Advisors of Case Management who provides medical staff oversight. Attends Utilization Management Committee meetings and reports on monthly denial/appeal activities. Works closely with Physician Advisor to provide on-going education and feedback to the medical staff as identified.

Provides performance indicators and opportunities for improvement for the case management department.

Acts as a liaison position between the hospital and the payer source, i.e. Medicare, Medicaid, Private Insurance Companies. Tracks and trend denials by DRG, Physicians, & payer and provide proactive measures & strategies to avoid and decrease denials in the future. Perform other case management related duties as designated by the Director or Team Leader.

Has the ability to present education to physicians/independent clinicians as needed in an attempt to avoid future denials.