Denial Case Manager

Title: Denial Case Manager- HIM

Location: Portsmouth United States

Job type: Hyrbid
Time Type: Full Time
Job Category: Nursing Professional
Requisition Number: DENIA003253

Job Description:

Current Employees: If you are currently employed at SOMC please log into UKG Pro to use the internal application process.

Department: Health Information Mangement

Shift/schedule: Full Time (40 hrs/wk), Hybrid

SUMMARY

• Works under the supervision of the Health Information Denials Manager. The primary responsibilities are to screen denied cases using criteria as outlined by the payer, both inpatient and outpatient, for appropriateness of peer-to-peer, rebilling or adjustments. Manage payer portals to ensure denials and requests are being addressed by the appropriate staff, assisting with appeal follow up as needed. Works closely with the Utilization Review team. Assist with denial submission as needed.

QUALIFICATIONS

Education:

• Graduate of an accredited school of practical nursing required
• Knowledge of Interqual, MCG or case management experience preferred
• Hospital Reimbursement Knowledge preferred

Licensure:

• Licensed to practice in OH as specified by health specialty (if applicable) required

Experience:

• Knowledge of advanced medical terminology and procedures, diagnosis, symptoms, disease processes treatments preferred.
• Denial management experience preferred

JOB SPECIFIC DUTIES AND PERFORMANCE EXPECTATIONS

The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.

• Performs clinical denial screening processes for inpatient and outpatient denials utilizing policies, contracts, regulations, MCG and InterQual criteria to include status denials, DRG validation denials, prior authorization and medical necessity denials.
• Reviews upheld clinical validation and status denials to prepare education for staff on prevention of future denials
• Ability to validate diagnoses by using standard screening tools for clinical validation.
• Works closely with Clinical Documentation Specialists and providers on DRG validation denial patterns for denial prevention.
• Works with Utilization review staff and manager on denial trends and patterns for denial prevention
• Works with other SOMC departments on adjustments and rebilling as needed.
• Works with outsource appeal companies
• Assists with closing out finalized appeals with both internal and outsource staff
• Reports data to be tracked
• Serves as a member of the denial team
• Monitors and manages information housed in insurance portals
• Assists with appeals submission as needed

Performs other duties as assigned

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Southern Ohio Medical Center is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, color, disability, ethnicity, gender identity, or expression, genetic information, military status, national origin, race, religion, sex, gender, sexual orientation, pregnancy, protected veteran status or any other basis under the law.