Corporate Denials & Appeals RN
Company: Nuvance Health
Posted on: April 5, 2021
Nuvance Health has a network of convenient hospital and outpatient
locations - Danbury Hospital, New Milford Hospital, Norwalk
Hospital and Sharon Hospital in Connecticut, and Northern Dutchess
Hospital, Putnam Hospital Center, and Vassar Brothers Medical
Center in New York - plus multiple primary and specialty care
physician practices locations, including The Heart Center, a
leading provider of cardiology care, and two urgent care offices.
Non-acute care is offered through various affiliates, including the
Thompson House for rehabilitation and skilled nursing services, and
the Home Care organizations. For more information about Nuvance
Health, visit .
Corporate Billing Compliance, Denials & Appeals RN Department: Case
Management Location: Danbury, CT
Purpose: The Billing Compliance, Denials & Appeals RN is
responsible for the systemwide retroactive medical necessity review
of medical services provided. The position is integral in the
revenue cycle on a system level and exists to partner with Case
Management and the System Business Office to support billing
compliance for Medicare one-day stay claims and to overturn claim
denials through the appeal process. The RN will conduct the
federally mandated review of all Medicare short-stay claims prior
to billing for the entire Health Quest system. The RN will review
and respond to all government payer (Medicare and Medicaid) denials
and is responsible for trending and reporting government payment
audits to the appropriate oversight committee (Medical Executive
Committee, Utilization Management Committee, Quality and
Performance Improvement Committee, etc.). This position is key in
denial prevention through auditing, education and training,
compliance monitoring, and process improvement of revenue cycle
functions. This role is also responsible for the assessment, plan,
coordination, and evaluation of initial and ongoing denials. The RN
obtains information on all denials occurring as related to
observation and inpatient stays. He/she identifies trends and
responds to the trends by recommending changes in practice and or
documentation of the providers to promote a reduction in the
- Concurrently reviews all medical and surgical denials and
provides a recommendation for responding or not responding to the
- Reviews denial data on a weekly basis to understand accounts
that have been written off to a denial or are currently in open
billing denial status. Increase accurate claim submission by
reviewing, researching, resolving, and trending claim issues, and
assisting in training and education.
- Works all denied cases to assess medical necessity and to
verify that appropriate billing practice guidelines are adhered to.
Works all inpatient denials for discharged patients from all payers
including government payers, managed care, and commercial payers.
Discusses any cases with Medical Director(s) or Physician Advisor
(s) as needed to establish the level of care and/or plan for
- Coordinates the submission of appeals to third-party payers
within allotted timeframes to prevent fiscal penalties. Appeals
payment of services denied by Medicare, Medicaid, and Commercial
payers by writing and presenting appeals to Insurance Reviewers,
Hearing Officers, and Administrative Law judges.
- Works with professional providers and hospital departments to
bill under the correct admission category and educate on required
documentation for the prevention of denials.
- Prioritizes assignments to avoid financial risk.
- Serves as a financial resource to the team.
- Provides follow-up processing for the Livanta IPRO Medicare
Appeal process only for the instances when a patient has initiated
a discharge appeal and has then agreed to the discharge and left
the hospital before the appeal determination has been made.
- Coordinates activities and strategies with the Care Management
Department, Patient Access, Billing, Managed Care, and Physician
QualificationsEducation and Experience Requirements:
- Associates Degree in Nursing
- 3 years experience in acute care Nursing
- 3 years experience as a Utilization Review Nurse in a payer or
acute care setting
- PREFER: Bachelor's Degree or Master's Degree in Nursing
- PREFER: At least 3 years of experience in revenue cycle
management, preferably in a hospital provider environment
- PREFER: Experience in billing cycle language and managed care
- PREFER: Experience with Medicare/Commercial appeals/denials
Minimum Knowledge, Skills, And Abilities Requirements
- Must be knowledgeable about financial impacts of payor coverage
associated with the organization and the patient
- Must be self-starter, highly motivated worker
- Ability to form positive, collaborative relationships with
hospital staff, providers, patients, and families
- Must have analytical abilities to assist in obtaining solutions
- Must be able to work independently, manage stress, and
- Must be able to manage multiple competing priorities and
maintain a calm demeanor in a stressful environment
- Ability to interact with all members of the surgical team and
administrative staff in a professional and courteous manner.
- Knowledge of InterQual and MCG as well as CMS Last Covered Day
or LCD / Non - Covered Day or NCD documentation
License, Registration, Or Certification RequirementsCurrent NYS
Registered Nurse (RN)
Keywords: Nuvance Health, Danbury , Corporate Denials & Appeals RN, Healthcare , Danbury, Connecticut
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