Registered Nurse - Denial/Appeal Administrator

November 12

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Boston Medical Center (BMC)

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5001 - 10000

Description

• Responsible for the Pre-denial/ Denial and appeal process in addition to Utilization Review. • Validate the patient’s placement based on nationally accepted admission criteria. • Use medical necessity screening tools to complete initial and continued stay reviews. • Secure authorization for the patient’s clinical services through timely communication with payers. • Follow the UR process and the pre-denial and denial/appeal process as defined in the job description.

Requirements

• Nursing degree: Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 years • Licensed to practice as a Registered Nurse in the Commonwealth of Massachusetts • Minimum 5 years or more related experience in a Utilization Management, Denials and Appeals and patient insurance/billing preferred • Work requires a comprehensive knowledge of clinical documentation and medical coding, and a working knowledge of patient financial billing regulations/requirements, reimbursement, managed care in order to understand the clinical and billing systems; review, interpret, and analyze clinical and patient financial reports and data; and plan, coordinate and prepare for corrections to accounts. • Such knowledge is generally acquired through completion of a Bachelor's degree and 5 years of experience in Case Management and an HMO setting. • Work requires a comprehensive understanding of medical records coding, patient billing policies and procedures and health insurance standards, as well as knowledge of supervisory/managerial techniques and principles in order to control hospital financial billing activities. • Establish and implement financial policies and plans; assist with the install of new modules; provide training for staff at various levels. • Such knowledge is normally acquired during 5 years or more progressively responsible experience in clinical areas and patient financial management environment. • Work requires advanced interpersonal skills necessary to work with physicians, hospital directors and managers to affect changes in clinical and fiscal operations, policies and procedures; to provide guidance, communicate and interpret complex patient billing and compliance information.