Denial Management Outcomes Specialist Raleigh

Job Description

Description

*This is an onsite position*

Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.

Summary:
Represents case management services on organization, division, service line, and departmental committees; contributes to qality assurance program for case management services; collaborates with case managers, and participates in all performance improvement activities to ensure patient safety.

Responsibilities:
1. Represents case management services on organization, division, service line, and departmental committees.
2. Contributes to the departmental quality assurance program for case management services: May be asked to perform focused reviews, monitors, or tracks trends to identify opportunities to improve utilization management, care coordination, discharge planning, clinical documentation, revenue cycle management, and social work services.
3. Develops a collaborative practice with the Case Managers and other co-workers that fosters departmental teamwork.
4. Works in partnership with the Attending Physicians and Physician Advisor(s) on case management initiatives.
5. Actively participates in departmental and organizational performance improvement (PI) initiatives to meet or exceed goals and outcomes and ensure patient safety.
6. Performs timely and thorough the initial utilization review for patient admitted in ED and hospitalized patients to ensure an appropriate level of care is assigned.
7. Performs a timely initial Case Management screening for patients admitted in ED and hospitalized patients and assigns the patient to an appropriate primary discharge planner.
8. Reviews and reconciles daily room and bed charges, tracking variance trends, and promptly reporting concerns to management.
9. Performs timely review of any reported clinical denials and accounts with payment discrepancy, advising Patient Financial Services on the appropriate action, tracking trends, and promptly reporting concern to management.
10. Audits the Failed Bill report daily and follows up with others to ensure the authorization is promptly obtained and delays trends are tracked for reporting purposes.

Other Information

Other information:
Education Requirements:
● Bachelor's degree from four-year college or university required or completion of an accredited graduate level advanced practice provider (APRN or PA) program.

Licensure/Certification Requirements:

• Licensed as a Registered Nurse or Advanced Practice Provider (ie, Nurse Practitioner, Physician Assistant, Certified Nurse Midwife) in the State of NC Required. Board certification if required by the department. CPUR; CPUM preferred.
  

Professional Experience Requirements:

● A minimum of five years utilization review and/or case management or related experience; or equivalent combination of education and experience. Master's degree in healthcare or business field and certification preferred.

● If an Associate's degree: 9 years of experience.

● If a High School diploma or GED: 13 years of experience.

● Language Skills: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public. Mathematical Skills: Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry. Reasoning Ability: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Job Details

Legal Employer: NCHEALTH

Entity: UNC REX Healthcare

Organization Unit: Rex Case Management Services

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Schedule: Day Job (Day) 10 am to 6:30 pm Monday through Friday

Location of Job: US:NC:Raleigh

Exempt From Overtime: Exempt: Yes