(RN) Denials/Appeals Management Specialist

MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C. region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.

Registered Nurse Admitting Appeals/ Denials (Fully Remote) Do you have the aptitude to work at home in your own environment? Bring your expertise to our talented Utilization Review Team! We are currently seeking a Registered Nurse with 2 to 3 years clinical nursing background, 2 to 3 years UR/ case management, and a minimum of 2 years' experience in hospital audits. The ideal nurse for this role would also be proficient in writing appeals letters, processing appeals, understanding the revenue cycle, reducing financial risk, and working with payers while having regulatory awareness. Although this is a remote position, it is supported by a collaborative team committed to delivering exceptional results. Our choice candidate would also foster a positive work ethic to enhance our team by introducing fresh ideas, helping with change management, and workflow efficiency to take our performance to the next level. The nurse for this role would feel comfortable working autonomously, and taking the initiative, while passionate about innovation, quality improvement and development. Please note, our office typically operates M-F, within the hours of 9 am-5pm with some scheduling flexibility available.

Completes appeal process for denied days for medical necessity that meets Interqual criteria, or appear to be clinically justified. Completes evaluation of all external denials for medical necessity received by the hospital and coordinates decision making regarding the feasibility of initiating an appeal for each external denial for medical necessity. Develops medical summaries of denied cases for review by hospital administration and for possible legal/Maryland Insurance Administrative (MIA) action, where indicated. Identifies and implements strategies to avoid denials and improve efficiency in delivery of care through review and examination of denials. Identifies system delays in service to improve the provision of efficient and timely patient care. Identifies process issues related to the concurrent Case Management system, including appropriate resource utilization and identification of avoidable days. Maintains records of concurrent and retrospective denial activity in conjunction with Case Management support staff. Monitors and tracks denials and appeal results, and coordinates information with Patient Financial Services (PFS). Reports data to the Director and Operations Review Committee. Meets with attending physicians and Physician Advisor, as appropriate, to clarify or collect information in the process of development of appeal letters. Participates in meetings and on committees and represents the department and hospital in community outreach efforts as required. Participates in the educational process for physicians and hospital staff to address issues that impact the number and type of denials. Serves as a resource to all staff in areas of utilization review/management. Utilizes and analyzes current medical/clinical information as well as medical record information to complete appeal letters. May interact with and assist third party payer reviewers to facilitate appropriate care and ensure payment of services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources. May utilize research methods to collect, tabulate, and analyze data in collaboration with the medical staff, and hospital performance improvement initiates. Implements strategies to correct or modify trends seen through data analysis and outcome monitoring. May serve as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, orientation and formal educational offerings. Assists in the orientation of new staff regarding the denials and appeals process. May manage the department in the Managers absence. Keeps Manager informed about issues related to staffing and problem areas. Keeps Manager informed about issues related to quality, risk, patient/family issues and concerns, allocation of resources and vendor/payer issues. Assists the Manager in monitoring performance issues. Contributes to the performance evaluation process by providing feedback to the Manager and assisting the creation of professional development plans for UR Coordinators. Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.