GENERAL SUMMARY/ OVERVIEW STATEMENT:Collaborates with appropriate individuals, departments and payers to insure appropriateness of admission, continued days of stay and reimbursement.Utilizing industry accepted utilization and or medical management criteria and can apply criteria to cases retrospectively to determine appropriateness of admission and days of stay, level of care, and over and under utilization.Demonstrates working knowledge about different industry criteria sets like MCAP, AEP, Milliman and Roberson, and Interqual.Demonstrates in depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs as well as commercial insurances and other types of plans: PPO, HMO, or indemnity.Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.Assists with the preparations of denial notices given to patients.Reviews cases retrospectively when requested by finance department to determine if admission relates to continue care for Medicare.Denial ManagementCoordinates the filing of appeals for clinical denials and works with other departments to ensure payment for care provided.Reviews denial letters and sends letters to other departments if appropriate.Communicates with attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.Works with physician advisor to write appeal letters for denied care and sends letters to insurance companies.Documents denials in the BWH/Partner's Denial Database.Follows up with insurance companies on claims status for clinical denials.Team Work
At Brigham Health, we place great value on being a diverse and inclusive community. Brigham Health and the Department of Nursing are dedicated to diversity, equity and inclusion as we aim to reflect the diversity of the patients in our local community. We have a dedicated focus on equity. Thus, we believe in equal access to quality care, employment and advancement opportunities encompassing the full spectrum or human diversity: race, gender, sexual orientation, religion, ethnicity, national origin and all the other forms of human presence and expression that make us better able to provide innovative and cutting-edge healthcare and research.
The Insurance Support Nurse participates in the timely management of denials that are received in the Care Coordination Department. Through sound knowledge of utilization management, the nurse is able to assess a patient's level of care after review of the medical record. The nurse is a part of the care coordination staff and works closely with care coordination, medical and nursing staff to appeal denied claims and expedite appeal processes and finale case closure. The nurse works closely with admitting and finance staff, to process denied claims.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
Assists with variety of functions and responsibilities of care coordination department to ensure that all state and federal mandates are followed. Participates in the ongoing evaluation of practice patterns and systems, support efforts to improve quality, cost and satisfaction outcomes.Expert on observation status and reviews observation patients as assigned.Assists in the completion of utilization reviews to insurers and intermediaries.Anticipates and troubleshoots claim and reimbursement issues.Assists in the review of Medicare reports as assigned.Participates in BWH and Partner's Finance projects.Active Member of the ATO/Denial Committee and UMC Committee. Other duties as assignedQualifications QUALIFICATIONS:
- RN required, MA license, BSN preferred.
- 5+ UM experience required
- Must have appeals and auditing experience
- Current experience leveling commercials and Governmental cases in real time with the last 2 years
- Knowledge and skills to differentiate levels of care required.
- Hospital utilization review and medical criteria sets required.
- Experience with leveling tool criteria required (such as Interqual or Milliman).
- Five years medical or surgical staff nurse experience required.
- Must provide a writing sample.
Certification in case management preferred.SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:
Previous experience in a hospital or health care setting, strong clinical assessment skills, excellent interpersonal skills including ability to work collaboratively and cooperatively within a team and internal and external customers; strong organizational skills and ability to set priorities: ability to compile data from concurrent and retrospective medical review to determine clinical appropriateness, level of care and discharge plan; excellent written and verbal communication skills, computer skills.WORKING CONDITIONS:
Works in a busy and at times stressful hospital/office environment. Must be able to work well and independently in a multidisciplinary group. Must be flexible. Travel required outside hospital/offices.EEO Statement
Brigham and Women's Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, creed, sex, sexual orientation, gender identity, national origin, ancestry, age, veteran status, disability unrelated to job requirements, genetic information, military service, or other protected status.
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