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Henry Ford Health System RN Coordinator -ClinicalDenials/Appeals - Contingent Day Shift - Henry Ford West Bloomfield in West Bloomfield, Michigan

GENERAL SUMMARY:

Under minimal supervision, this position specializes in follow-up of denied and rejected claims from all commercial, contracted and non-contracted payers, including preparing appeal letters. Reviews all denials for medical necessity and appeal ability utilizing clinical judgment and applying InterQual criteria. Provides clinical utilization management expertise. Provides education, formal and informal, to facilitate denial management strategies. Serves as a liaison to key customers that include ancillary departments, physicians and payers.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

  • Familiarity with all aspects of utilization/denial management and expertise to analyze if all admitted patients are appropriate for services requested and rendered.

  • Retrospectively communicates to obtain required authorizations for treatment from the respective payers.

  • Refers denied cases to the assigned PAS (Physician Advisory Services) personnel to determine next steps after initial review.

  • Demonstrates a strong clinical knowledge base to review developmentally appropriate assessment, plan of care and the interventions for patient outcome.

  • Utilizes clinical judgment, including applying Interqual screening to evaluate denied claims for potential appeal

  • Coordinates all aspects of denial management.

  • Reviews payer denial/rejection rationale and develop rebuttal appeal within the timely filing timeframes, per payer.

  • Provides timely response to payer requests, inquiries and/or complaints.

  • Tracks and inputs pertinent information to the appropriate system(s) and the tracking log.

  • Prepares, processes, mails, files, and/or scan the following, updating the appropriate activity log as required:

  • Denial letters according to NCQA, CMS and DOL standards and timeframes.

  • Approval letters according to CMS standards and timeframes.

  • Provider appeal letters according to NCQA standards and timeframes along with preparation of supporting documentation.

  • Update ECIN and other programs to reflect current status of accounts, such as appeal, approval and denial decisions as received by insurance company response.

  • Assumes responsibility for maintaining tracking of all denials and appeals, including copies of all letters for the appeal process, authorization numbers, avoidable days and dollars recovered.

  • May provide input to denial management dashboard reports for the management team to support process improvements.

  • Liaison to medical records and patient financial services regarding medical documentation for level of care, coding and correct billing status, including release of bills when suppressed for pending appeal.

  • Participates in physician office staff education related to utilization management as requested.

  • Demonstrates proficiency in all utilization management software and hospital information systems used to obtain clinical information on patients.

  • Demonstrates effective communication skills to collaborate with a variety of persons, including the patient, public, coworkers, guests, payers, outside agencies and medical staff.

  • Performs other related duties as required.

EDUCATION/EXPERIENCE REQUIRED:

  • Registered Nurse with a valid, unrestricted, State of Michigan License required.

  • Minimum 3-5 years of clinical experience required.

  • Bachelor of Science Nursing required or three years Denial/Appeal/Utilization Management experience.

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Overview Henry Ford Health System, one of the largest and most comprehensive integrated U.S. health care systems, is a national leader in clinical care, research and education. The system includes the 1,200-member Henry Ford Medical Group, five hospitals, Health Alliance Plan (a health insurance and wellness company), Henry Ford Physician Network, a 150-site ambulatory network and many other health-related entities throughout southeast Michigan, providing a full continuum of care. In 2015, Henry Ford provided $299 million in uncompensated care. The health system also is a major economic driver in Michigan and employs more than 24,600 employees. Henry Ford is a 2011Malcolm Baldrige National Quality Award recipient. The health system is led by President and CEO Wright Lassiter III. To learn more, visitHenryFord.com. Benefits Whether it's offering a new medical option, helping you make healthier lifestyle choices or making the employee enrollment selection experience easier, it's all about choice. Henry Ford Health System has a new approach for its employee benefits program - My Choice Rewards. My Choice Rewards is a program as diverse as the people it serves. There are dozens of options for all of our employees including compensation, benefits, work/life balance and learning - options that enhance your career and add value to your personal life. As an employee you are provided access to Retirement Programs, an Employee Assistance Program (Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness and access to day care services at Bright Horizons Midtown Detroit, and a whole host of other benefits and services. Employee's classified as contingent status are not eligible for benefits. Equal Employment Opportunity/Affirmative Action Employer Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health System is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.
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