About the job
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.
Education/Experience Required
- Minimum three-five (3-5) years of clinical experience required. Bachelor of Science Nursing required or three (3) years Denial/Appeal/Utilization Management experience.
- Knowledge of hospital billing and payer regulations, including criteria for patient status determination, and tools/software used for determination.
Certifications/Licensures Required
- Registered Nurse with a valid, unrestricted, State of Michigan License required.
Additional Information
- Organization: Corporate Services
- Department: Payor Audit
- Shift: Day Job
- Union Code: Not Applicable