Defense Audit Denials RN
Palomar Pomerado Health
San Diego, California
Specializing in you...serving San Diego´s inland North County communities for more than 50 years, PPH is a family of outstanding healthcare facilities that cover an area of more than 800-square miles.
Specializing in you...serving San Diegos inland North County communities for more than 50 years, PPH is a family of outstanding healthcare facilities that cover an area of more than 800-square miles. As the largest hospital district in Southern California, we are also one of the most diverse. From our state-of-the-art Cardiac Care and Rehabilitation Facilities and busy Trauma Center to Home Healthcare, we deliver a full spectrum of health services to meet the needs of every member in our community.
We have an excellent opportunity for a Full-Time Defense Audit Denials RN who will be responsible for the clinical review of all charges on patient encounters in five primary areas of focus: 1) payer defense audits 2) pre-billing chart to charge reviews on high risk patient encounters for compliance and /or lost revenue 3) post billing chart to charge reviews as areas of risk are identified 4) clinical denials to mitigate the loss of revenue 5) refund requests to review for missing charges
Responsibilities include:
Summarize reviews into clear and concise reports for management review.
Reports to include recommendations for corrective action, which can include staff training and process improvement; creates and maintains database of reviews performed and reports trends to management at least monthly; serves as a resource to clinical areas to identify lost charge improvement opportunities.
Possess analytical ability to design methods, collect and review data, formulate appropriate solutions and compile reports.
This individual prioritizes work based on findings and risk; performs multiple tasks and modifies review approaches based on the organizations changing situations and needs, and follows through to achieve final resolution.
Ability to effectively communicate, both written and verbal, with all levels of the organization.
Work independently and as a cohesive team member seeking opportunities throughout PPH to improve effectiveness in charge capture and increased accuracy of clinical documentation.
Responsible for coordinating and managing appeals for clinical denial of payment by medical record review with input from the physician advisor, attending physician, nurse case managers, and UR nurses.
Serves as a liaison between patient financial services (PFS).
Provides Case Management (CM)and Utilization Review (UR) for appeal-denial related issues.
Generates formal letters of appeal to the insurance carrier.
Responsible for collecting and maintaining data relating to appeals and outcomes.
Explores opportunities for improvement in an effort to increase hospital reimbursement and decrease the rate of clinical denials.
Maintains ongoing education and working knowledge of insurance regulations and claims audit.
Maintains data spreadsheets with ability to prepare and present reports as requested.
Maintains and utilizes excellent interpersonal, verbal and written skills effectively with ability to work independently to prioritize workload to meet appeal deadlines.
Performs other duties as assigned.
Follows PPH rules, policies, procedures, applicable laws, and standards.
Carries out the mission, vision, values, and quality commitment of PPH.
We promote a philosophy that encourages growth and satisfaction. We provide a work environment that is open and empowering, where you can experience a wide range of clinical, educational, and management opportunities. We also support a healthy balance between your personal and professional lives. We are located in an area that is enriched with a sense of belonging, where everyone pulls together in a common philosophy of life. Its an area that affords all who live here the luxury to pursue any interest or lifestyle they choose.
Requirements
Minimum Education: As required by certification and/or licensure
Preferred Education: Bachelors Degree in Nursing
Minimum Experience: 2 years hospital denials management, 4 years experience in an acute care facility and/or health care consulting; and Quality Assurance/Utilization Review
Preferred Experience: 4 years hospital denials management, 5 years experience in an acute care facility and/or health care consulting; Quality Assurance/Utilization Review
Required License: Current CA RN License and Valid Drivers License
We invite you to join us in our Mission to Heal, Comfort, and Promote Health in the Communities We Serve!
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