RN -Denial Reviewer - remote

Job Description

Description

PeaceHealth is seeking a RN Denial Reviewer for a Full Time, 1.00 FTE, Day position. The salary range for this job opening at PeaceHealth is $54.61 – $81.91. The hiring rate is dependent upon several factors, including but not limited to education, training, work experience, terms of any applicable collective bargaining agreement, seniority, etc.

Serves as subject matter content expert and change agent with in-depth knowledge of workflow related to denials and appeals management. Performs in depth reviews of clinical DRG downgrade denials to draft appeal letters for submission to payers. Provides support in development of the clinical denial process, letter templates, and process improvements.

*** Ideal candidate will have experience with clinical DRG-downgrade denials in the inpatient acute care setting.

Details of the Position:

• Ensures the overall accuracy, completeness and timeliness of the clinical documentation to support the clinical validity of denied diagnoses/DRG's

• Performs in depth clinical reviews of denied records to author and submit initial as well as second level appeals to the payers.

• Develops a deep understanding of denial payer pattern, serving as an educator/liaison to providers and caregivers to facilitate accuracy of clinical documentation, resulting in an understanding of documentation needs for denial mitigation.

• May author, implement, and maintain written policies, procedures, and processes related to clinical denial/appeals. This includes formatted templated design for diagnosis specific appeals.

• Acts as a resource for best practices in clinical documentation, impact of Medicare guidelines and facilitates educating key stakeholders.

• Participates as a member of the CDI Task Force.

• Applies knowledge of current Medicare part A and how it impacts DRG assignment to the review of clinical documentation.

• Performs other duties as assigned.

What You Bring:

Education

• Accredited School of Nursing Required: or

• Doctor of Medicine Required: or

• Master's Degree Preferred: Master of Science in Nursing or

• Bachelor's Degree Preferred: Bachelor of Science in Nursing.

Experience

• Minimum of 5 years Required: Experience as a Clinical Documentation Specialist in a hospital program and

• Preferred: Experience with 3M 360 Encompass, CAC, and Epic software and

• Preferred: Knowledge of pathophysiology and disease process and

• Preferred: Knowledge of value-based purchasing and other quality metrics affecting the clinical documentation integrity program and

• Preferred: Experience with clinical DRG-downgrade denials in the inpatient acute care setting

Credentials

• Required: Registered Nurse In state of practice or

• Required: Certified Clinical Documentation Specialist or

• Required: Medical Doctor - Washington in state of practice

Skills

• Strong verbal, written and interpersonal communication skills. (Required)

• Ability to interact effectively with providers and all levels of staff to achieve quality outcomes. (Required)

• Ability to effectively communicate clinical information. (Required)

• Ability to analyze/problem solve. (Required)

• Computer skills to include word processing, spreadsheet and data entry. (Required)

• Strong organization skills with the ability to work in a fast-paced environment independently and as part of an interdisciplinary team. (Required)

• Good critical thinking skills, able to assess, evaluate and teach. (Required)

• Working knowledge of all areas of adult medicine. (Required)

Department / Location Specific Notes

Additional Registered Nurse licensure may be required within one year of hire, for work performed in other states where PeaceHealth does business.

Working Conditions

Lifting

• Consistently operates computer and other office equipment.

• Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.

• Sedentary work.

Environmental Conditions

• Predominantly operates in an office environment.

Mental/Visual

• Ability to communicate and exchange accurate information.

• The worker is required to have close visual acuity to perform an activity such as: preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading.

PeaceHealth is committed to the overall wellbeing of our caregivers: physical, emotional, financial, social, and spiritual. We offer caregivers a competitive and comprehensive total rewards package. Some of the many benefits included in this package are full medical/dental/vision coverage; 403b retirement plan employer base and matching contributions; paid time off; employer-paid life and disability insurance with additional buyup coverage options; tuition and continuing education reimbursement; wellness benefits, and expanded EAP and mental health program.

See how PeaceHealth is committed toInclusivity, Respect for Diversity and Cultural Humility.

For full consideration of your skills and abilities, please attach a current resume with your application. EEO Affirmative Action Employer/Vets/Disabled in accordance with applicable local, state or federal laws.