Clinical Denials Prevention & Appeals Specialist RN Job Danbury area,Connecticut USA,Healthcare

SUMMARY

The purpose of the Denial Prevention Nurse is to ensure that all patient admissions are appropriately status within the first 12‑24 hours and that ongoing communication (electronic and telephonic) with payers ensures timely approval of all hospital days, preventing delays in reimbursement. This role plays a critical part in preventing payment denials by providing timely and accurate clinical information to all payers, while ensuring compliance with CMS requirements, guidelines, and standardized published criteria to support the medical necessity of patient admission and continued hospital stays.

This role will require specialized system skills, best practice application of investigating payer practices, successfully challenging payers as they prevent obstacles and deny claims and escalating any egregious payer behaviors to internal leadership for assistance in resolution.

RESPONSIBILITIES

Review all inpatient admission and observation cases using Inter Qual, or Milliman Care Guidelines or CMS 2 Midnight Rule (depending on payer) within 12‑24 hours of admission, seven days a week for assigned shifts.

Complete an initial screening review within the first few hours of decision to admit from ED and communicate with appropriate Provider if initial status is to be re‑considered.

Identify incomplete clinical reviews in work queues and complete them within two hours whenever possible. If clinical information is not available by the time the lack of a review may result in a denial, elevate to the appropriate Provider/VPMA.

Identify and complete clinical reviews required for submission to specific payers.

Validate admission orders for all new admits/observations/outpatients daily.

Ensure that the patient status order documented in the chart aligns with the MCG and/or Inter Qual criteria, or the CMS Two‑Midnight Rule, to support the appropriate status and level of care.

Prioritize review of all outpatient observation and outpatient bedded cases at least every 8 hours for conversion to inpatient status or discharge opportunities.

Participate in daily Observation Huddles.

Conduct concurrent reviews for all payers daily for the first three days of admission, then every 2‑3 days, or more frequently if criteria are waning.

Submit concurrent reviews to payers to ensure authorization of all days for per diem and percentage of charge reimbursement payers.

If concurrent inpatient case does not meet medical necessity review criteria during the first level review, discuss with the attending MD to obtain additional clinical information and documentation to support inpatient level of care. If the case still does not meet, send to the Physician Advisor (PA) for a second level review.

Forward cases that require secondary physician review to appropriate resource (e.g., Physician Advisor).

Resolve any discrepancy at the time of review. If unable to resolve, elevate to the PA and Utilization Review (UR) Leadership.

Coordinate with the care team in changing patient status, as needed. Notify the care team when patient does not meet medical necessity per Inter Qual or MCG guidelines or 2 MN Rule and elevate appropriately.

Document and proactively communicate relevant clinical information to payers for authorizations for treatments, procedures, and Length of Stay – submit clinical information as required by payers.

Ensure completion and delivery of required patient notices (by onsite team member). These include but are not limited to: HINNs, Condition Code 44, MOON, Connecticut notice of conversion, etc.

Tracking and trending all appeals and communicating on a daily/regular basis with the Denials Management team.

Assists with informing Managed Care contracting team with necessary contractual language to protect organization financial position specific to inpatient medical necessity requirements.

Employs creative solutions with team members and leadership to prevent denials.

Performs other duties as assigned.

OTHER INFORMATION

Education Skills Experience
Minimum 5 years experience in acute care Nursing
Proficiency in Milliman and Inter Qual Guidelines required
Minimum of 2‑3 years experience as Utilization Management Nurse in an acute care…


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