RN Denials/Charge Audits, Revenue Cycle

Job Description

Under the supervision of the Revenue Cycle Director, using established policies and procedures, performs the denials appeal process on selected cases. Utilizes knowledge of utilization management rules and processes to focus on recouping denied reimbursement. Confers with RN and Social Work Care Management, Revenue Management team members, Peer Review Organizations (PRO) and other managed care review agencies to assure certification of the patient's entire stay so that the hospital receives maximum reimbursement. Has knowledge of numerous payers, review requirements. Is also responsible for executing charge related audits from government entities, payers, patients and compliance.

Responsibilities

Accuracy/Productivity
  • Reviews all elements of denied accounts or charge audits. Identifies accounts that need contractual adjustments or rebilling and sends to the appropriate department for correction
  • Utilizes InterQual or MCG criteria, based on payor manuals, to effectively appeal medical necessity denials
  • Records denial activity in Epic system following department procedures
  • Records charge audit findings in the Epic system following department procedures

Accuracy/Productivity
  • Reviews all elements of denied accounts or charge audits. Identifies accounts that need contractual adjustments or rebilling and sends to the appropriate department for correction
  • Utilizes InterQual or MCG criteria, based on payor manuals, to effectively appeal medical necessity denials
  • Records denial activity in Epic system following department procedures
  • Records charge audit findings in the Epic system following department procedures

Work Queue Management
  • Manages assigned work queue(s), completing appeals within the defined appeal timeframe
  • Alerts leadership to errors or issues with WQ management, including accounts inappropriately flowing into WQ

Prepare and Participate in Payer Ops meetings
  • Represent assigned hospital in a professional and knowledgeable manner.
  • Review cases to discuss at meetings with manager prior to adding to agenda.
  • A nalyzes initial and fatal data to identify trends, shares findings with revenue cycle leadership to drive process improvement

Outreach Education and Training 1
  • Prepares summaries that pinpoint root cause of charge/billing errors for service line leaders
  • Supports global denial prevention and mitigation efforts by attending billing unit meetings
  • Responds to clinical department questions and reviews cases as necessary, to assist with correct charge capture process and procedures.
  • Attends educational sessions, training sessions and task forces sessions as directed


Qualifications

Minimum Required: Associate's Degree in Health Information, Medical Coding, Business, Or Related. Preferred Degree: Bachelor's Degree in Health Care Administration, Health Information, Business Administration, or Related. | Current coding/compliance certification through the national association of AHIMA, AAPC, HCCA, or other relevant professional association. | Minimum Required: 3 - 5 Years equivalent experience. Preferred: 6 - 10 Years equivalent experience.