Denials Nurse Auditor Location: United States Department: RN Job Description: Description The Denials Nurse Auditor works under the supervision of the manager of PFS Denials. The Denials Nurse Auditor is responsible for completing, appealing, tracking, and reporting clinical denial reviews to determine the appropriate actions for post-billing denials. This Individual will combine clinical, financial, and regulatory knowledge and skill to reduce financial risk and exposure caused by payer denials for rendered services. The Denials Nurse Auditor has highly developed knowledge and skills in areas of: Medical Necessity, Authorizations, Experimental/Investigational denials, payer audits and filing appeals as well as Government and Non-Government payor requirements with Denial Management.

Responsibilities

• Completes clinical review of appropriate post-claim denials; prepares clinical discussion and appeal letters for denied accounts.
• Consults clinical and hospital appeal guidelines; provides appeal direction using payer guidelines to appropriate departments via monthly denials meetings.
• Ensures compliance with all federal, state, and local regulations governing rendered patient services and reimbursement.
• Reviews and analyzes specific audit information and provides education to other caregivers both internal and external to the PFS Denial Management team. Identifies, and initiates clinical and hospital quality improvement initiatives focused on improving both quality indicators and outcomes.
• Responds to all internal and external requests for information, data, and/or education specific to clinical and hospital Denial Management.
• Collaborates with Revenue Cycle, Admissions, Coding, and other departments as needed to answer clinical questions specific to denial management. Seeks consultation from appropriate departments as required to expedite clinical review of potential denials.
• Researches industry best practices and recommends process improvements to leadership.
• Participates in the review of workflow processes. Recommends and participates in the implementation of process improvements.
• Recommends policies which support the direction of the Denials Management Team to improve and reduce denials.
• Responsible for other miscellaneous duties assigned by PFS Leadership.
• Other duties as assigned.

Education

• Bachelor's Degree - Graduate of school of nursing, BSN - Required

Work Experience

• 5 Years - Experience in health care as a registered nurse, preferably in revenue cycle. - Required
• Excellent understanding of financial and health care strategies. - Required

Licenses and Certifications

• Registered Nurse (RN) - State Licensure/Or Compact State Licensure - Registered Nurse license by the State of Missouri - Required Upon Hire

Travel Requirements

Qualifications

Skills and Abilities Essential Technical/Motor Skills

• Input data, type, manipulate small equipment, speak clearly, and answer telephone.

Interpersonal Skills

• Exceptional oral/written communication skills
• Ability to independently research using critical thinking skills
• Effectively resolve complex denials
• Excellent organizational skills and attention to detail
• Competence in Microsoft Office applications

Essential Physical Requirements

• Lifting, moving, reaching, bending, stooping, and climbing.

Essential Mental Abilities

• Analyze, interprets, calculates, manipulates, understands, follows rules, memorize, organize, assess, explain, speak in front of group.

Essential Sensory Requirements

• Visual skills, hearing

Exposure to Hazards

• Electrical output of personal computer, eye/neck strain.

Other Skills and Abilities