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Registered Nurse - Clinical Payment Resolution Specialist

Company: Strategic Staffing Solutions
Location: Livonia
Posted on: February 24, 2021

Job Description:

Job Description: Clinical Payment Resolution Specialist/Nurse LiaisonPOSITION PURPOSEResponsible for reviewing all post-billed denials (inclusive of clinical denials) for medical necessity and appealing them based upon clinical expertise and clinical judgment within the Hospital and/or Medical Group revenue operations ($3-5B NPR) of a Patient Business Services (PBS) center. Serves as part of a team of clinical payment resolution colleagues at an assigned PBS location responsible for identifying and determining root causes of clinical denials. Responsible for leveraging clinical knowledge and standard procedures to track appeals through first, second, and subsequent levels, and ensuring timely filing of appeals as required by payers, in addition to promoting departmental awareness of clinical best practices. The position will report directly to the Supervisor Clinical / Coding Payment Resolution.ESSENTIAL FUNCTIONS---Coordinates denial management processes (Clinical and Administrative/Technical accounts, focusing upon retrospective follow-up and appeal processing) with the objective of appropriately maximizing reimbursement based upon services delivered and ensuring that the claim is paid/settled in the most timely manner possible: oSupports Supervisor Clinical/Coding Payment Resolution with communication and follow-up processes related to rejections, denials and appeals, ensuring that such activities are tracked, trended and reported to key stakeholders across the various impacted departmentsoCoordinates rejection, denial and appeal activities with Ministry Organization (MO) based Utilization Review/Case Management departments;oReviews and understands utilization review and coverage guidelines for multiple payers;oIdentifies solutions to issues affecting reimbursement as it relates to denial prevention (prospective and concurrent) and provides summary of findings to Supervisor to deliver feedback to Ministry departmentsoSupports the maintenance of a denial management database, standard report sets, letter template and other key job aids.oServes as a resource contact, providing clinical information as requested by payers. May facilitate coordination information with payers in order to secure appropriate reimbursement;oSupports Supervisor Clinical/Coding Payment Resolution as the liaison to members of the medical staff and other MO colleagues, regarding denial management processes, systems and requirements. May provide clinical input to Pre-Service staff in order to facilitate authorization approvals;oAssists in marketing efforts and the education of physicians, physician office staff and MO colleagues;oEstablishes checks and balances to ensure PBS and MO-based key performance indicators are accurate and that goals/targets are met, andoSupports the development of effective internal controls that promote adherence to applicable local, state, federal laws, and program requirements of accreditation agencies and health plans.---Identifies opportunities for process improvement and participates in the implementation of such as needed. Assists in the design and development of system enhancements while monitoring congruency with process goals and regulatory mandates.---Maintains a strong working relationship with the associated Ministry Payer Strategy team's in order to ensure proper identification, resolution, and coordination of clinical denials in alignment with payer environment and expected reimbursement ---Provides detailed understanding or aptitude for resolving denials based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons and constructing warranted appeals for defined populations as directed by the Supervisor Clinical / Coding Payment Resolution,---Interprets data, draws conclusions, and reviews findings with all levels of Payment Resolution Specialist for further review. ---Serve as a resource to Payment Resolution Specialists providing guidance and mentorship in achieving positive operational outcomes.---Keeps abreast of denial trends and in regulations concerning healthcare financing and payer relations through journals and professional continued education programs, seminars, and workshops.---Other duties as needed and assigned by the Supervisor Clinical / Coding Payment Resolution.---Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.MINIMUM QUALIFICATIONS---Must possess a demonstrated knowledge of denial management functions. Registered Nurse and a graduate of an accredited school of nursing plus at least four (4) years of nursing experience, to include two (2) years of utilization review/case management, managed care or comparable patient payment processing experience. Must have current registration with the state Board of Nursing Examiners or have a temporary permit to practice nursing in the assigned state.---Knowledge of and experience in health care including government payers, applicable federal and state regulations, healthcare financing and managed care.---Knowledge of and experience in case management and utilization management.---Knowledge of insurance and governmental programs, regulations and billing processes (e.g., Medicare, Medicaid, Social Security Disability, Champus, Supplemental Security Income Disability, etc.), managed care contracts and coordination of benefits is required. Working knowledge of medical terminology and medical record coding experience (ICD-9, CPT, and HCPCS) are highly desirable. ---Customer service background is required. Working knowledge of computer operations and electronic interfaces is required. Formal software course training is preferred.---Ability to interact effectively with multidisciplinary teams, including physicians and other clinical professionals internally and externally.---Possesses detailed understanding or aptitude to learn and understand denials resolution based on patient status, length of stay, level of care, missing pre-certification, or other clinical reasons.---Must possess in-depth familiarity with third party billing requirements and regulations, and writing appeals.---Must be comfortable operating in a collaborative, shared leadership environment.

Keywords: Strategic Staffing Solutions, Livonia , Registered Nurse - Clinical Payment Resolution Specialist, Healthcare , Livonia, Michigan

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