Current UPHS employees must apply HERE
RN Clinical Denial Management Coordinator Full time Days at Princeton Medical Center
Job ID: 192447
Category: Management/Leadership
Work Type: FT
Location: Plainsboro, NJ, United States
Work Schedule: M-F 8-5
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Description
Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work?
Summary:
- The RN Clinical Denial Management Coordinator performs advanced level work related to clinical denial management and is responsible for managing claim denials related to referral, authorizations, notifications, non-coverage, medical necessity, and others as assigned. The RN Clinical Denial Management Coordinator conducts comprehensive reviews of the claim denial, account/guarantor notes associated with the denial, and the medical record to make determinations if a revised claim needs to be submitted, if a retro authorization needs to be obtained, if a written appeal is needed, or if no action is needed. The RN Clinical Denial Management Coordinator writes and submits professionally written appeals, which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language and ensures appeals are submitted timely and tracked through final outcome. The incumbent will also handle audit-related / compliance responsibilities and other administrative duties as required. This incumbent will actively manage, maintain, and communicate denial / appeal activity to appropriate stakeholders and report suspected or emerging trends related to payer denials to Revenue Cycle management. Additionally, the RN Clinical Denial Management Coordinator anticipates and responds to a wide variety of issues/concerns. The incumbent works independently to plan, schedule, and organize activities that directly affect hospital and physician reimbursement and assists in creating and maintaining documentation of key processes as this role is key to securing reimbursement and minimizing organizational write offs.
Responsibilities:
- Completes clinical review of appropriate pre- and post-claim denials; prepares clinical discussion and appeal letters for appeal of appropriate patient accounts.
- Ensures compliance with all federal, state, and local regulations governing rendered patient services and reimbursement.
- Reviews and analyzes current audit information to educate colleagues both internal and external to the revenue cycle. Identifies, and initiates clinical quality improvement initiatives focused on improving both clinical quality indicators/outcomes and financial metrics.
- Responds to all internal and external requests for information, data, and/or education specific to clinical Denial Management.
- Collaborates with Revenue Cycle, Physicians, Admissions, Coding, and Coordinated Care staff to answer clinical questions specific to denial management. Seeks consultation from appropriate disciplines/departments as required to expedite clinical review of potential denials.
- Oversees collection and utilization of operational and benchmarking data to recommend and set targets for improvements; researches industry best practices and recommends process improvements to leadership.
- Evaluates reporting, statistics, and relevant surveys to assess departmental operational and fiscal performance. Participates in the review of program and workflow processes. Recommend s and participates in the implementation of process improvements. Monitors and measures process changes.
Credentials:
- Registered Nurse - NJ (Required)
- License in area of specialty i.e. RN
Education or Equivalent Experience:
- Bachelor of Science Nursing (Required)
- And Three (3) years’ experience working within case management, utilization management or denial management preferred And Experience with business letter writing, e.g., appeals preferred.
Live Your Life's Work
We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.
Current UPHS employees must apply HERE
