Denials Coordinator

GENERAL SUMMARY:

Responsible for assisting the denials team in managing patient medical denials through the request of documentation and assistance in preparing cases for presentation and evaluation. Collaborates with utilization management, case management, revenue cycle, and the physician advisor.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Oversees the departmental budgetary procedure to ensure proper operational and capital planning, appropriate and efficient use of resources, and consistent compliance to budgetary and fiscal controls.

3. *Reviews all denial accounts for categorization, level of appeal, and special requirements for initiating appeals.

4. *Reviews and compiles required denial documentation and submits in a timely manner to ensure compliance with required timelines.

5. *Supports the appeal process by ensuring that proper documentation is provided to support appeals of unauthorized inpatient days or days denied for lack of documentation.

6. *Manages new denials. Reviews hospital records for medical necessity and routes to the appropriate teams or personnel.

7. *Screens new denials and assigns preliminary denial reasons.

8. Enters and schedules Peer to Peer reviews when necessary.

9. *Tracks and documents tasks to assist in preparing and following up on pending cases.

10. *Tracks and monitors concurrent and retrospective cases within electronic records.

11. Assists in auditing for administrative and medical necessity denials.

12. Assists with paperwork and follow-up of self-denied cases, and Condition Code W2s.

13. Assists in gathering data for performance of retrospective denials.

14. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in the field of expertise.

15. Participates in meetings, committees, and department projects as assigned.

16. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*". Refer to the Job Description Guide for the definition of essential and non-essential job functions. Attach Addendum for positions with slightly different roles or work-specific differences as needed.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of computer hardware equipment and software applications relevant to work functions.

2. Ability to communicate effectively both verbally and in writing.

3. Ability to perform crucial conversations with desired outcomes.

4. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff.

5. Ability to problem solve and engage independent critical thinking skills.

6. Ability to maintain confidentiality relevant to sensitive information.

7. Ability to prioritize work demands and work with minimal supervision.

8. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act or bachelors degree in relevant health care field required. Minimum of two (2) years of experience working within case management, utilization management, denial management or equivalent required. Clinical experience preferred.

OTHER CREDENTIALS / CERTIFICATIONS:

None

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) - Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.