Denial Prev Specialist Registered Nurse FT Days at AdventHealth

Date Posted: 10/10/2019

Job Snapshot

  • Job Schedule
    Full-Time
  • Location:
    Maitland, FL
  • Job Category
  • Date Posted:
    10/10/2019
  • Job ID:
    19018607
  • Job Family
    Patient Financial Services
  • Travel
    No
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth Central Florida

Job Description


Description
YOU ARE REQUIRED TO SUBMIT A RESUME WITH YOUR APPLICATION!
 
RN Denial Prevention Specialist - AdventHealth - Maitland
Location Address: 900 Winderley Place

Top Reasons to work at AdventHealth - Maitland

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Work Hours/Shift:   Full Time M-F 8am-5pm
 

You Will Be Responsible For:


Demonstrates, through behavior, AdventHealth Orlando’s service standards.

  • Utilizes software to process clinical information, giving priority to cases with nearest procedure schedule date and/or reimbursement at risk. Processes each pending procedure on the clinical work queue by reviewing available physician documentation in Cerner and/or Athena or other system. Requests further documentation according to payor medical coverage policies and/or LCD/NCD. Communicates the clinical status via work queue activity flow to the Pre-Access Department to secure timely authorization.
  • Pulls surgery schedule for all Central Florida Division South Region facilities as far in advance as necessary to review procedures with established high denial rates and risk of CMS non-compliance with LCD/NCD.  Reviews the available records against the LCD/NCD and requests the required documentation from the physician offices through the support staff.  Documents action taken in the Utilization Management (UM) section of Cerner. Utilizes the CMS and/or First Coast Service Option website to obtain the appropriate LCDs/NCDs, ensuring use of the most up-to-date policy which is accomplished by reviewing the CMS MedLearnMatters news updates.
  • Coordinates with appropriate Pre-Access personnel to initiate the ABN or HINN process in advance of the scheduled procedure when clear contraindication or non-coverage condition exists.
  • Reviews surgery schedule for all Central Florida Division South Region facilities for inappropriate preplanned status for Medicare accounts per CMS Inpatient Only List/C-indicators and documents in the UM section of Cerner Care Manager for the assigned UM Manager to assist with appropriate status management (IP vs. OBS). 

Qualifications

What You Will Need:

Required:
  • Proficiency in basic computer skills and programs (i.e. Word, Outlook, Excel, etc.)
  • Familiarity in Cerner EMR navigation, demonstrating mastery of data extrapolation
  • Working knowledge of InterQual criteria and its application
  • Graduate of School of Nursing
  • Three years’ experience as RN in an acute clinical setting
  • Bachelor’s or other higher-level degree in the field of nursing, management, or business
  • Current valid State of Florida or multi state license as a Registered Nurse
Preferred:
  • Experience with Medicare/commercial utilization review
  • Experience obtaining commercial authorizations
  • Working knowledge of CMS Inpatient Only List, HCPCS/CPT code look-up
  • Working knowledge of Medicare Guidelines as pertains to the patient in the acute care setting
  • Master’s or other higher-level degree in the field of nursing, management, or business
  • Certification specialty in utilization management, managed care, or other applicable professional certification
  
Job Summary:

The RN Denial Prevention Specialist will receive daily work assignment from the Team Lead and/or manager to work adjunctively with the Denial Prevention Team to meet deadlines and productivity goals.  This RN Denial Prevention Specialist works in collaboration with Pre-Access and HIM, striving to achieve payer authorization and appropriate patient statusing (Inpatient (IP) vs. Observation (OBS) vs. Outpatient (OP)) prior to the performance of identified medical procedures or hospital stays as designated in the team work queue to prevent ‘No Authorization’ denials.  The RN Denial Prevention Specialist also reviews the Surgery Schedule across all hospitals within the Central Florida Division South Region for procedures with established high denial rates and risk of Centers for Medicare and Medicaid Services (CMS) non-compliance with Local Coverage Determination (LCD) and National Coverage Determination (NCD), with the goal of ensuring the required documentation is present in the medical record prior to the procedure being performed in order to negate pre-payment and post-payment CMS denials and to help ensure regulatory compliance. If a clear contraindication or non-coverage condition exists, the RN Denial Prevention Specialist will notify the appropriate Pre-Access personnel to initiate the Advance Beneficiary Notice of Noncoverage (ABN) or Hospital Issued Notice of Noncoverage (HINN) process as far in advance of the scheduled procedure as possible. The RN Denial Prevention Specialist: maintains thorough knowledge of payer medical policies and guidelines as well as CMS payment policies and guidelines; keeps abreast of payer requirements for obtaining authorizations and follows through accordingly to prevent loss of reimbursement; actively participates in team workflows and meetings; continuously strives for process improvement by communicating findings and areas to improve workflow to team members; actively participates in outstanding customer service while accepting responsibility in maintaining relationships that are equally respectful to all; and adheres to rules and regulations of applicable local, state, and federal agencies. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.



This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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