Cedars-Sinai RN Denials Management Prog Coordinator (Registered Nurse) in Los Angeles, California
Under the direction of the Manager, the denials management program coordinator is responsible for overall management and communication of clinically based appeals between Cedars-Sinai and outside payers. The program coordinator will also act as a liaison and point of contact to/for division and other internal representatives for denial and appeal inquiries. In addition, the program coordinator will actively manage, maintain and communicate to manager denial and appeal activities, trends, and recommended corrective action plans. Supports research, participates in strategic planning, both long and short term, and assures patient advocacy.
Main responsibilities include but are not limited to:
Supports Manager in the response process for the organization on all government audits. Writes reviews and ensures responses are thorough and delivered timely. These include responses to all applicable entities.
Reviews non-government denials and determines appropriates of denial based upon applicable guidelines, professional judgment, and/or community standards and responds as per department policy.
Identification and facilitation of educational opportunities with other departments, providers, and payers to decrease denials and improve quality of service to patients. Conduct informal and formal education programs within the organization.
Works in collaboration with other departments and health plans to develop corrective action plans to address identified trends in reasons for denials.
Utilizes electronic data base to track reason for denial, result of denial review as it relates to ability to appeal, date of appeal actions, outcome of appeal if appropriate.
Performs case management review of issues related to compliance with government payer coverage issues as well as commercial denials.
Provides oversight of the patient classification programs including but not limited to the pre-procedure review program and applicable vendors, and engagement.
Registered nurse; Bachelor’s degree preferred
License/Certification Requirements: CA RN license
Experience: Minimum of 3 years of clinical experience in an acute care/hospital experience, or 3 years of experience in utilization review, coding, or case management experience preferred.
A high level of clinical knowledge required to participate collaboratively with all members of the care team.
Strong broad-based clinical knowledge and understanding of pathology/physiology of disease processes.
Must possess a minimum computer competency comprised of a working knowledge of Windows or comparable system (specifically including keyboarding and mouse skills). As applicable to individual job duties and expectations, employee must additionally possess a working knowledge of word processing, spreadsheets, presentation development, e-mail, browsers, and online reporting.
Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.