RN Coordinator- Payor Audit - Full Time - Days

Full Time 40 Hours

Eligible for full Time Benefits

Remote - must be able to sit at desk for 8 hours 

GENERAL SUMMARY: 

Under minimal supervision, this RN specializes in follow-up of denied and rejected claims from all commercial, contracted and non-contracted payers, including reviewing and preparing appeal letters. Working within a centralized department, reviews all medical necessity and coding related denials and appeal ability utilizing clinical judgment and applying appropriate medical necessity criteria. Provides clinical expertise to provide education, formal and informal and facilitates denial management strategies. Serves as a liaison to key customers that include, hospital ancillary departments, physicians, payers, and auditors. 

PRINCIPLE DUTIES AND RESPONSIBILITIES: 

1. Familiarity with all aspects of utilization/denial management and expertise to analyze if all outpatient services and admitted patients are appropriate for services requested and rendered. 

2. Retrospectively communicates to obtain required authorizations for treatment from the respective payers. 

3. Refers denied cases to the assigned Medical Director and/or PAS (Physician Advisory Services) personnel to determine next steps after initial review. 

4. Demonstrates strong clinical knowledge and judgment, including applying appropriate medical necessity screening to evaluate denied claims for potential appeal.

5. Coordinates all aspects of denial management, including payer follow-up. Employs escalation techniques to resolve cases in a timely manner. 

6. Reviews payer denial/rejection rationale and develops rebuttal appeal within the timely filing timeframes, as determined by individual payer contracts. 

7. Provides timely response to payer requests, inquiries and/or complaints. 

8. Tracks and inputs pertinent information to the appropriate system(s) and the tracking log. Identifies trends and reports through proper escalation pathways. 

9. Prepares, processes, mails, files, and/or scans all necessary documents. Including but not limited to: 

• Denial letters according to NCQA, CMS and DOL standards and timeframes. • Approval letters according to CMS standards and timeframes. 

• Provider appeal letters according to NCQA standards and timeframes along with preparation of supporting documentation. 

10.Updates EPIC and other programs to reflect current status of accounts, such as appeal, approval and denial decisions as received by insurance company response. 

11.Assumes responsibility for maintaining tracking of all denials and appeals, including copies of all letters for the appeal process, authorization numbers, avoidable days and dollars recovered. 

12.May provide input to denial management dashboard reports for the management team to support process improvements and acts as a liaison between front end teams and post-pay denial/appeal process.