Denials Manager RN
On-siteSan Gabriel, California, United States
Job Summary
Appeal all denials using InterQual criteria and medical necessity while collaborating with revenue cycle teams, payers, and facility directors to resolve underpayments and maximize reimbursement. Evaluate, track, and trend denial data to implement prevention programs and establish tools for measuring denial tracking. Manage peer-to-peer processes for concurrent denials, create weekly reports for denials meetings, and lead RAC preparedness for facility audits. Provide education and training to medical and nursing staff on denial prevention, California Code of Regulations, and HMO compliance. Submit appeals within strict deadlines using appropriate templates and supporting documents.
Required Qualifications
- Current California RN License
- Current BLS Card
- Graduate of an accredited RN School of Nursing
- Four years recent acute care experience in a critical care setting
- Two years Utilization Management/Case Management experience
- Working knowledge of MCG, Intensity of Service/Severity of Illness criteria
- Working knowledge of Title XXII and Title XIX
- Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, Shared Risk, and Managed Care
- Ability to negotiate with the physicians, payers, and customers
- Ability to track outcomes and report findings
- Able to problem solve effectively
- Ability to use clinical knowledge to identify potential quality issues
- Provides proper notification of absence or tardiness within established departmental time frames
Desired Qualifications
- BSN preferred
- Four years recent acute care experience in a critical care setting (preferred)
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