Supv Denial Resource Center RN

Baylor Scott & White Health • Madison, WI • 3d ago

JOB SUMMARY

The Supervisor, Denial Resource Center provides direction regarding cases submitted to the Denial Resource Center (DRC) for clinical appeal. The Supervisor provides guidance to appeal writers and administrative assistants on daily workflow and ensures appropriate distribution of workload and cases.

ESSENTIAL FUNCTIONS OF THE ROLE

Supervises Denial Resource Center (DRC) RNs and Administrative Assistants through the monitoring of staff workload, developing staff assignments, and reviewing of productivity. Handles escalations from DRC RNs.

Conducts quality reviews, advises with peer-to-peer appeals and denial research.

Analyzes deadline report and worklists and assigns high priority, special cause accounts. Evaluates incoming cases for readiness for appeal and appropriate expertise assigned for appeal.

Recommends and implements quality improvement initiatives

Supports orientation of new staff and ongoing training

Reviews cases for appropriateness for referral for external appeal such as ALJ, THHSC, VA complaints. Writes clinical appeals, as needed.

Serves as a resource for staff related to complex accounts.

Interfaces with Collectors, Administrative Assistants and Appeal Writers to assess effectiveness of work processes and acts upon opportunities for improvement with account handoffs and communication regarding cases.

Serves as resource for IT and training on BSWH systems used in the DRC (e.g. Midas, AEOS, EPIC, Allscripts, PatCom, Nuance, Microsoft Office Suite, etc.).

Prepares reports as assigned for use within the department and external customers. This includes but is not limited to routine reports for verifying status of accounts using MIDAS, TRAC, AEOS.

KEY SUCCESS FACTORS

Understands commercial and government regulations for reimbursement including, but not limited to: InterQual, RAC/MAC, Clinical Policy Bulletins, national and local coverage determinations, CMS admission status requirements, TJC conditions of participation, CMS appeals process, including Administrative Law Judge.

Knowledge and understanding of nursing and patient care standards and procedures.

Knowledge of laws, rules and regulations; standards and guidelines of certifying and accrediting bodies; hospital and department/unit standards, protocols, policies and procedures governing the provision of nursing care applicable to the area of assignment.

Knowledge of medical terminology; principles and practices of health promotion, risk reduction, illness and disease prevention and management; medications and drugs, common dosages, their physical and physiological effects, and possible adverse reactions.

Knowledge of medical and professional nursing ethics and patient privacy rights.

Must be able to communicate thoughts clearly, both verbally and in writing.

Interpersonal skills to interact with a wide-range of constituencies.

Must have critical thinking and problem-solving skills.

Ability to observe changes in the medical condition of patients and effectively communicate these changes to other nursing staff members and physicians/providers.

Ability to provide age-specific, quality, patient-centered care to all patients through the nursing process and standards of nursing practice with sensitivity and respect for the diversity of human experience and to develop, evaluate, implement and, as necessary, modify a patient care plan to meet the needs of individual patients.

Ability to make tactical decisions around the allocation and direction of the work of supervised employees using established guidelines, policies and/or procedures.

Ability to make effective hiring and termination recommendations.

Ability to train and evaluate performance of supervised staff.

General computer skills, including but not limited to: Microsoft Office, information security, scheduling and payroll systems, electronic medical documentation, and email.

ACM or CCM license preferred.

BENEFITS

Our competitive benefits package includes the following

Immediate eligibility for health and welfare benefits

401(k) savings plan with dollar-for-dollar match up to 5%

Tuition Reimbursement

PTO accrual beginning Day 1

Note: Benefits may vary based upon position @type and/or level

QUALIFICATIONS

EDUCATION - Associate's

MAJOR - Nursing

EXPERIENCE - 3 Years of Experience

CERTIFICATION/LICENSE/REGISTRATION -

&nbspRegistered Nurse (RN)

As a health care system committed to improving the health of those we serve, we are asking our employees to model the same behaviours that we promote to our patients. As of January 1, 2012, Baylor Scott & White Health no longer hires individuals who use nicotine products. We are an equal opportunity employer committed to ensuring a diverse workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.

Similar Jobs

Senior Technical Program Manager

Oracle • Madison, WI • 15min ago

Management & Administrative

Job Description OCI (Oracle Cloud Infrastructure) Region Build Organization is currently in need of a Technical Program Manager (TPM) to join our fast-growing team. Technical Program Managers (TPM) rely on their mastery...

15min ago

Go to Apply

Wccf Auxiliary Operator

MADISON GAS & ELECTRIC CO • Madison, WI • 57min ago

JOB REQUIREMENTS: General Purpose of Work Under general supervision, positions in this classification perform plant operation, testing, maintenance, and administrative functions as required for the safe and efficient ope...

57min ago

Go to Apply

Campus Cores Facilitator

UW-MADISON • Madison, WI • 57min ago

JOB REQUIREMENTS: Current Employees: If you are currently employed at any of the Universities of Wisconsin, log in to Jobs Hub to apply through the internal application process.Job Category:Academic StaffEmployment Type:...

57min ago

Go to Apply

Linux Desktop Administrator

UW-MADISON • Madison, WI • 58min ago

58min ago

Go to Apply

Specialty Nurse Case Manager (Rheumatology)

Veterans Affairs, Veterans Health Administration • Madison, WI • 1h ago

Hospital & Medical

Summary This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific eligibility requirements per VHA policy and submit your EDRP applica...

1h ago

Go to Apply

Operating Room RN

Veterans Affairs, Veterans Health Administration • Madison, WI • 1h ago

Summary The Operating Room (OR) Registered Nurse (RN), known as a Perioperative RN, is responsible for administering intraoperative care to the surgical patient in our 6-suite operating room. Responsible and accountable...

1h ago

Go to Apply

Neurology Accountant

UW-MADISON • Madison, WI • 2h ago

Hospital & Medical

2h ago

Go to Apply

Community Engagement Manager

Oracle • Madison, WI • 2h ago

Management & Administrative

Job Description About the Role: As a Community Engagement Manager for OCI, you will be responsible for collaborating and building meaningful partnerships and engagement opportunities between OCI, educational institutions...

2h ago

Go to Apply

Line Cook

THE PFISTER HOTEL • Madison, WI • 2h ago

Retail & Hospitality

JOB REQUIREMENTS: Description Line Cook Location: Hilton Madison Monona Terrace - Madison, WI Schedule: Full-Time | Morning and Weekend Availability Required Salary Estimate: \$17-\$19/hour based on experience Bring Flav...

2h ago

Go to Apply

Preventative Maintenance Engineer

THE PFISTER HOTEL • Madison, WI • 2h ago

Retail & Hospitality

JOB REQUIREMENTS: Description Preventative Maintenance Technician Location: Hilton Madison Monona Terrace - Madison, WI Schedule: Flexible Schedule Preferred Wage Estimate: \$20/hour - Starting Protect Our Property\'s Pe...

2h ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.