Wiki Denials prevention

Mbueno2

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Deland, FL
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Hello, everyone I have been given an opportunity to become a denials prevention specialist. I just need clarification on what this role actually does and what they are to see on a day to day basis. Also what is to be expected? Please and thank you, I just want to be prepared before start date.

Marisa B.
 
Hi , hope you are up to the task, Here is one job description:
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.



Knowledge, Skills, Education, & Experience 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
• Ability to find the required CMS LCD/NCD and comprehend the clinical requirements for the given procedure and regulatory implications.
• Investigative review knowledge of the medical record
• Proficiency with using multiple computer applications interchangeably including but not limited to: Athena, Experian, SharePoint and the like.
• Ability to access payer websites to look for medical coverage policies and apply the criteria to the specific procedure.
• Ability to communicate with all parties (i.e., staff, team members, payers, etc.) in a helpful and courteous manner while extending exemplary professionalism. Anticipates and responds to inquiries and needs in an assertive, yet courteous manner. Demonstrates positive interdepartmental communication and cooperation. Communicates professionally with an acceptable use of English (speaking, reading, and writing)
• Ability to articulate in both written and verbal communication to formulate clear and concise rationale in clinical terms/language
• Ability to follow oral and written directions
• Critical thinking and problem-solving skills regarding the clinical review and criteria specific to a procedure or hospital stay as indicated by the specific payer
• Ability to research procedure of all types, clinical areas, medical specialties, and practice arenas to determine the required documentation to substantiate authorization providing a positive impact on reimbursement
• Ability to multi-task and work in a potentially stressful, fast-paced environment with tight timelines for work completion
• Ability to respect the autonomy of remote work environment and work with people of diverse backgrounds
• Ability to be self-directed when required, and work independently with limited supervision
• Excellent customer service skills and communication etiquette
• Experience with Medicare/commercial utilization review (Preferred)
• Experience obtaining commercial authorizations (Preferred)
• Working knowledge of CMS Inpatient Only List, HCPCS/CPT code look-up (Preferred)
• Working knowledge of Medicare Guidelines as pertains to the patient in the acute care setting (Preferred)
• Proficiency in use of Excel, Word, Outlook, Skype, and Skype Meeting (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
• Bachelors or other higher-level degree in the field of nursing, management, or business
• Masters or other higher-level degree in the field of nursing, management, or business (Preferred)



Licensure, Certification, or Registration Required:

• Current valid State of Florida or multi state license as a Registered Nurse
 
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