Florida Hospital Maitland seeks to hire RN Denial Specialist who will embrace our mission to extend the healing ministry of Christ.

Facility Profile:

Established in 1908, Florida Hospital is one of the largest not-for-profit healthcare systems in the country, caring for more than a million patients each year. The Maitland Office Plaza houses our highly skilled teams that support our hospital system including Marketing, Patient Financial Services, Revenue Management, the Credit Union and Human Resources. The Trickel Building, a two-story office structure, creates an atmosphere of health and healing, with a healthy-style café and quaint chapel. The main lobby is filled with lush greenery and a light trickle of water, creating a holistic environment.

Work Hours/Shifts:

Flexible

Job Summary:

The RN Denial Specialist formulates appeals in response to denials from all payers including government entities across the Central Florida Division- South Region. Creates synergies, maintains bidirectional communication, and acts as the liaison between Pre-Access, PFS, clinical and administrative partners within the hospital setting and beyond, ensuring open communication and collaboration toward common goals. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

Knowledge, Skills, Education, & Experience Required:

• Articulate in both written and verbal communication to formulate clear and concise arguments/rationale in clinical terms/language
• Critical thinking and problem-solving skills regarding clinical review, criteria and response to audits and denials.
• Ability to research denials from all types of clinical areas, medical specialties, and practice arenas and articulate a cohesive argument.
• Ability to multi-task and work in a stressful and fast paced environment that has very tight timelines for work completion
• Works independently
• Knowledge of InterQual and MCG as well as CMS LCD/NCD documentation
• Mastery of EMR data extrapolation
• Able to go out to payer websites to look for policy language and use it articulately in denial rebuttals
• Experience with Medicare/Commercial appeals/denials (Preferred)
• Working knowledge of Excel, Word and Outlook (Preferred)
• Experience in billing cycle language and managed care contract language (Preferred)
• Graduate of school of nursing
• Three years’ experience as RN in an acute clinical setting
• Bachelor’s degree or other higher-level degree in field such as nursing, management, business (Preferred)

Licensure, Certification, or Registration Required:

• Current valid State of Florida or multi state license as a Registered Nurse
• Certification specialty preferred in Utilization Management, managed care or other applicable professional certification (Preferred)

Job Responsibilities:

Demonstrates through behavior Florida Hospital’s Core Values of Integrity, Compassion, Balance, Excellence, Stewardship and Teamwork as outlined in the organization’s Performance Excellence Program

• Works closely with the DM manager and/or Director to assess appeals and strategize appeal prevention, based on tracking and trending the work they see each day. Serve as the denial experts to the enterprise for any questions specific to denials for all payer groups including governmental payers.
• Reviews EMR, payer website, and other ancillary computer outlets as needed to develop appeal response and determine medical documentation necessary to respond to each denial at each level of appeal based on established criteria sets such as InterQual/MCG
• Works closely with the PFS teams to exchange information in a timely manner, to establish a continual cycle of process improvement and denial mitigation/prevention.
• Works with HIM, PFS, and DM Manager/Director to develop strategic plan for appeals and gather data as needed to establish action plans for denial prevention.
• Discusses any cases with Medical Director(s) as needed to establish level of care and/or plan for appeal.
• Works closely with the Denial Management Revenue Integrity Research group to obtain all necessary medical research needed to successfully appeal all denials.
• Participates in any meetings, phone conferences or webinars as needed to either appeal cases or expand knowledge regarding the appeal process, changing rules and regulations, and understanding the contract language that the hospital operates under. Attends phone conferences and in person meetings with the DM manager and Director as required to discuss scorecards, data, rules and regulations, contract updates and work prioritization.
• Works closely with the pre-authorization team to assess all IP vs. Obs short stay cases pre-bill to drop clean bills within the cooling off period.
• Works all denied OP procedure, therapy, ED only cases, to assess medical necessity and to verify that appropriate billing practice guidelines are adhered to. Works all IP denials for discharged patients from all payers including government payers, managed care, and commercial payers

If you want to be a part of a team that is dedicated to delivering the highest quality in patient care, we invite you to explore the RN Denial Specialist opportunity with Florida Hospital Maitland and apply online today.

Job Keywords:

RN Denial Specialist, Utilization Management, Maitland