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Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

Supports denials, appeals, and compliance activities within the Payer Audit and Clinical Denials Management Department. Conducts audits to ensure activities conform with regulatory requirements. Supports policy development, implementation, and staff/provider education relative to management of payer denials from all payers, Federal and State as well as commercial managed care payers. Active participant of the Revenue Cycle Committee, this position supports managed care activities, appeals documentation and defense processes representing the organization both internally and externally. The position works both independently and with the multidisciplinary team to evaluate and improve denial management activity, documentation, and the appeals process. The primary goal is to assess clinical care rendered to the patient that is billed to the payer and to recover all appropriate funding where indicated. This position is instrumental in determining root causes based on denial activity and recommending standard work for clinical staff and providers. The overriding goal is to minimize any loss in revenue and maintain and/or improve the organization's compliance with documentation, coding, and billing activities. Assists in the advancement of the professional practice environment by communicating the NGHS nursing strategic direction and focusing on activities that support the nursing strategic direction. Assists with overall clinical governance and other projects as assigned. Is a professional member of VOICE providing feedback on issues being addressed at meetings. 

Minimum Job Qualifications

• Licensure or other certifications: Licensed to practice as an RN in Georgia. Professional certification in either a clinical or education specialty within two (2) years.

• Educational Requirements: Bachelors Degree

• Minimum Experience:  Three (3) to five (5) years case management or utilization management experience, including acute med-surg and/or critical care experience. Must have expertise with InterQual and Milliman disease management ideologies.

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:

• Preferred Educational Requirements:

• Preferred Experience: In-depth familiarity with third party billing requirements and regulations, and billing documentation requirements

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Strong analytical and organization skills  

• Candidate must possess a strong ability to research, analyze, and interpret clinical data in determining the best course of action in pursuing denied and underpaid hospital revenue

• Must be able to demonstrate knowledge and skills necessary to provide care appropriate to patients served

• Excellent interpersonal communication and negotiation skills

• Strong analytical, data management, and PC skills

• Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement

• Knowledge of third-party regulations

• Proficient in payment reviews, hospital information systems, and coding methodologies

• Works collaboratively with multi-disciplinary departments and specializes in pursuit of a persuasive clinical appeal

• Has knowledge and expertise to appeal best clinical practices and promote continuous performance improvement at NGHS

• Ability to recognize and uphold best clinical practices and continuous operational improvement at NGHS

• Detail oriented

• Strong clinical background in multiple areas

• Ability to work independently and as a cohesive team member

Essential Tasks and Responsibilities

• Reads and interprets the clinical care provided to the patient.

• Analyzes and makes an informed clinical judgment on the validity of the denial for the purpose of preparing an appeal. 

• Coordinates denial appeal follow-up, analyzes provided clinical documentation, criteria application outcome, provider input, physician advisor input, and complete review of the medical record.

• Assures action is taken within the appeal time frames to reserve the denial.

• Serves as a liaison of Patient Financial Services for continued appeal process to final resolution.

• Supports development improvement strategies in response to identified patterns.

• Expert in the application of medical necessity screening tools and alerts CM management should criteria not be utilized to its maximum benefit.

• Demonstrates extensive knowledge and skill in the use of multiple hospital systems.

• Seeks out physician advisor support where indicated.

• Active participant in developing and providing staff and provider education.

• Liaison between the auditors/payers and the organization.

• Maintains an accurately recorded data base of all denial activity and participates in developing and sharing routine reports with providers and hospital staff as appropriate.

• Maintains thorough working knowledge of discharge planning, utilization management, case management, InterQual criteria, performance improvement, and managed care reimbursement.

• Interprets and utilizes clinical research of evidenced based medicine to support and provide validity to written appeals.

• Serves as a clinical resource consultant by providing clinical expertise.

• Receives and places calls to multiple customers (MDs, MD office staff, insurance companies, peers, etc.) and works toward resolution. 

• Maintains current knowledge of Centers of Medicare and Medicaid (CMS) and payer regulations required for processing and preventing denials where trends are identified.

• Accesses and understands Government data bases ensuring payer rationale for specific denials reasons. Shares and elicits support from the medical staff to formulate a response to specific denials where indicated.

• Assumes accountability for helping to actively recover or minimize potential loss to large sums of NGHS revenue where clinical care is appropriate and supported in the medical record.

• Successfully completes mentoring class. Assists with mentoring of Registered Nurses when other mentor resources have been assigned. May mentor more as desired.

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Moderate, Frequently 31-65% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Occasionally 0-30%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Frequently 31-65%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals. 

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.