Denials Management Appeals Nurse (Anesthesia)

About the Role

The role requires strong attention to detail, excellent communication skills, and the ability to work effectively in a fast-paced environment. You will be part of a dynamic team that values collaboration, innovation, and critical thinking. As a Denials Management Appeals Nurse, you will have the opportunity to make a meaningful impact on the lives of patients and their families.

Shriners Children's is committed to providing a supportive and inclusive work environment that fosters growth and development. With a strong focus on employee well-being, the company offers a range of benefits and perks that promote work-life balance and career advancement.

What You Will Do

• Perform comprehensive analytic reviews of clinical documentation to determine if an appeal is warranted
• Utilize clinical background to address clinical denials and write sound, compelling factual arguments for appealing denials
• Maintain detailed knowledge of Third Party Payors and Governmental Payors clinical/medical necessity criteria
• File compliant appeals in accordance with Third party and governmental contracts
• Review assigned cases comparing the bill to the medical record
• Perform a detailed comparison of charges to documentation to ensure services documented have been captured through the charge process
• Review documentation to ensure that services typically performed with specific procedures are being documented so that charge capture may occur
• Review findings with hospital representatives and obtain an agreement on the discrepancies
• Follow up on appeals in a timely fashion to ensure that cases are completed
• Re-check mathematical computations before finalizing letter and report
• Update status of all cases assigned on a minimum weekly basis

What We Are Looking For

• 5 years of clinical healthcare/hospital experience
• 3 years of related Anesthesia experience
• Third Party Payor Appeals/Revenue Cycle experience
• Current RN license in State of employment
• Working experience with Utilization Review activities and general knowledge of TJC, PRO, and other regulatory bodies
• Strong analytical and problem-solving skills
• Excellent communication and interpersonal skills
• Ability to work effectively in a fast-paced environment
• Strong attention to detail and organizational skills

Nice to Have

• Bachelor's degree, BSN highly desired
• Case Management certification
• Experience with Excel and other software applications
• Knowledge of medical necessity/clinical denials from third party payors or governmental payors

Benefits and Perks

• Medical coverage on the first day of employment
• 403(b) and Roth 403(b) Retirement Saving Plan with matching contributions of up to 6% after one year of service
• Paid time off, life insurance, short term and long-term disability
• Flexible Spending Account (FSA) plans and a Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected
• Tuition reimbursement, home and auto insurance, hospitalization, critical illness, and pet insurance
• Opportunities for professional growth and development
• Collaborative and inclusive work environment

• Tip: Highlight your experience with denials management and appeals in your resume and cover letter, and be prepared to provide specific examples during the interview process.
• Tip: Develop a strong understanding of Third Party Payors and Governmental Payors clinical/medical necessity criteria to increase your chances of success in this role.
• Tip: Showcase your analytical and problem-solving skills by providing examples of how you have utilized data to drive business outcomes in previous roles.
• Tip: Demonstrate your ability to work effectively in a fast-paced environment by highlighting your experience with prioritizing tasks and managing multiple projects simultaneously.
• Tip: Prepare to discuss your experience with Utilization Review activities and regulatory bodies, such as TJC and PRO, during the interview process.
• Tip: Be prepared to provide examples of how you have maintained detailed knowledge of medical necessity/clinical denials from third party payors or governmental payors in previous roles.