Job Summary: The RN Denial/Defense Auditor is responsible for the management and review of all clinically based appeals to payers and Managed Care defense audits. Reviews electronic medical records to ensure sufficient documentation by clinicians, and appropriate billing/coding for denied days and medical necessity. Prepares clinical appeals documentation for all payer types. Applies appropriate clinical judgment during review of denied days and medical necessity to assess whether denial can be appealed. Collaborates with physicians and leadership to enhance denial management and improve clinical documentation improvement efforts. Key responsibilities include keeping abreast of the complex and changing regulations, developing and implementing a proactive clinical denials management strategy to ensure that the organization receives full and compliant reimbursement. Ensures that the organization meets all regulatory reporting requirements, government and payer audits, appeals, ensuring compliance with government program regulations. Position must be able to communicate and articulate complex concepts to high level audiences, improving and influencing internal business processes and anticipating and meeting future denials management service needs.
Educational Requirements: Bachelor's Degree in Nursing is required. Medical coding certificate is desired.
Certification/Licensure Requirements: Current Licensed Registered Nurse in the state of Virginia.
Experience Requirements: 5-7 years of clinical nursing experience is required. Experience in case management/utilization management is preferred. Knowledge of CPT and ICD 9/10. Knowledge of hospital revenue cycle. Knowledge of insurance contract rates and terms. Understanding of collections process. Understanding of CMS billing and payment rules.