Supv Denial Resource Center RN

Baylor Scott & White Health • Providence, RI • 17h 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

Account Manager III

Renaissance • Providence, RI • 4h ago

Management & Administrative

About Renaissance When you join Renaissance®, you join a global leader in pre-K-12 education technology! Renaissance's solutions help educators analyze, customize, and plan personalized learning paths for students, allow...

4h ago

Go to Apply

Multimedia Marketing Intern

EBSCO Information Services • Providence, RI • 4h ago

Sales & Marketing

EBSCO Information Services (EBSCO) delivers a fully optimized research experience, seamlessly integrated with a powerful discovery platform to support the information needs and maximize the research experience of our end...

4h ago

Go to Apply

Commercial Banking Data Lead

Citizens • Johnston, RI • 7h ago

Finance, Accounting & Banking

Description About the Role A Commercial Data Lead to drive the strategic use of data across the Commercial business. This role will be responsible for shaping and executing the commercial data strategy, enabling data-dri...

7h ago

Go to Apply

Account Executive - Managed Services Sales

Red River • Providence, RI • 11h ago

Management & Administrative

Job Description At Red River Managed Services, we provide a welcoming and positive workplace where everyone feels valued and able to do their best work, fostering a one-team mentality. Our employees work together to fost...

11h ago

Go to Apply

Software Engineer, Infrastructure

Meta • Providence, RI • 12h ago

IT & Engineering

Summary: Meta is seeking talented engineers to join our teams in building cutting-edge products that connect billions of people around the world. As a member of our team, you will have the opportunity to work on complex...

12h ago

Go to Apply

Staff Software Engineer

Fujifilm • Providence, RI • 12h ago

IT & Engineering

Position Overview Join FUJIFILM Biotechnologies and help build the digital platforms that accelerate the future of life sciences. We're looking for a Staff Software Engineer to set technical strategy, lead cross-team arc...

12h ago

Go to Apply

Software Engineer, Infrastructure

Meta • Providence, RI • 12h ago

IT & Engineering

12h ago

Go to Apply

Construction Clean Up Worker

PeopleReady • Fall River, MA • 15h ago

Trucking & Construction

Construction Clean Up Worker PeopleReady of New Bedford, MA is now hiring Construction Clean Up Workers in Fall River, MA! Apply today and you could start as soon as tomorrow. As a PeopleReady associate you'll benefit fr...

15h ago

Go to Apply

Manufacturing Technician III

Nitto Denko Corp. • Milford, MA • 16h ago

Hospital & Medical

About this opportunity : As a Manufacturing Technician III, you'll be responsible for the implementation of assigned production operations working within defined production schedules in a cGMP environment. Key Responsibi...

16h ago

Go to Apply

Customer Service Representative

Saint-Gobain • Bristol, RI • 16h ago

Management & Administrative

The Customer Service Representative (CSR) is expected to be the primary customer contact for assigned customers within the Operations Team in the Bristol, RI site. The CSR will work closely with the sales team and supply...

16h 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.