Denial Resource Center RN
Company: Baylor Scott & White Health
Posted on: November 25, 2022
The Denial Resource Center Registered Nurse (RN) is responsible for
Baylor Scott & White Health denial management functions. The Denial
Resource Center (DRC) is responsible for receiving claim denials
and appealing to payors to promote appropriate reimbursement from
payors to BSWH hospitals. The DRC RN manages denials from all
payors, including denials for lack of medical necessity, pre-cert,
re-cert, billing, coding, and patient status.
ESSENTIAL FUNCTIONS OF THE ROLE
Receives clinically denied claims from the BSWH Central Business
Office, or directly from the payor, and appeals the denied claim
through all appropriate levels of appeal as defined by the
Reviews the denied patient's medical record to analyze the
following in order to appeal the denied claim: Appropriate level of
care, appropriate admission status, medical necessity for the
hospitalization, appropriate application of InterQual criteria,
appropriate LOS and discharge planning
Reviews and any associated physician office records that may assist
with the appeal process and/or regulatory documentation
Engages the attending and consulting physicians as well as the Care
Coordination Medical Directors when needed to assist in appeal
Performs chart analysis on quality surveillance and special studies
as requested, i.e. Novitas, OIG, CMS probes.
Identifies opportunities for and participates in process
Identifies denial trends by DRG, type, procedure, etc.
Assists leadership in developing medical necessity documentation
forms to meet regulatory requirements.
Participates in pertinent meetings, including hospital AWO
meetings, to share denial trends and activities seen within the DRC
with key stakeholders.
Documents denial information and appeal findings into the DRC
electronic system for analysis of denial trends and appeal
KEY SUCCESS FACTORS
Understands commercial and government regulations for reimbursement
including, but not limited to: InterQual, RAC/MAC, Clinical Policy
Bulletins, national and local coverage determinations, CMS
admission status requirements, TJC conditions of participation, CMS
appeals process, including Administrative Law Judge.
Knowledge and understanding of nursing and patient care standards
Knowledge of laws, rules and regulations; standards and guidelines
of certifying and accrediting bodies; hospital and department/unit
standards, protocols, policies and procedures governing the
provision of nursing care applicable to the area of assignment.
Knowledge of medical terminology; principles and practices of
health promotion, risk reduction, illness and disease prevention
and management; medications and drugs, common dosages, their
physical and physiological effects, and possible adverse
Knowledge of medical and professional nursing ethics and patient
Must be able to communicate thoughts clearly, both verbally and in
Interpersonal skills to interact with a wide-range of
Must have critical thinking and problem-solving skills.
Ability to observe changes in the medical condition of patients and
effectively communicate these changes to other nursing staff
members and physicians/providers.
Ability to provide age-specific, quality, patient-centered care to
all patients through the nursing process and standards of nursing
practice with sensitivity and respect for the diversity of human
experience and to develop, evaluate, implement and, as necessary,
modify a patient care plan to meet the needs of individual
General computer skills, including but not limited to: Microsoft
Office, information security, scheduling and payroll systems,
electronic medical documentation, and email.
ACM or CCM license preferred.
Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1Note: Benefits may vary based upon
position type and/or level
- EDUCATION - Associate's
- EXPERIENCE - 2 Years of Experience
- CERTIFICATION/LICENSE/REGISTRATION -
Registered Nurse (RN)
Keywords: Baylor Scott & White Health, Dallas , Denial Resource Center RN, Healthcare , Dallas, Texas
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