RN Appeals Nurse Case Manager - Business Office
Experienced RN Case Manager - Revenue Cycle: DeKalb Medical, North Decatur Campus
Full-time Case Manager position currently available for experienced case manager to work in finance/revenue cycle. Previous experience in finance, payer, utilization and appeals in hospital setting is preferred. Duties will include:
- Monitor insurance denials by running appropriate reports and contacting insurance companies to resolve claims denied for clinical reasons
- Identify coding or clinical documentation issues and work to correct the errors in a timely manner.
- Identify problem accounts and escalates as appropriate
- Update the patient account record to identify actions taken on the account.
- Work with guarantors to secure payment on account balances outstanding for clinical reasons
Writing Appeal Letters for Authorization and Medical Necessity Denials
Must be self-starter with exceptional communication skills both written and oral. Hours are 8a-5p M-F. Must have active unrestricted RN License, BSN preferred but not required.
The Case Manager functions as a member of both a unit-specific and an organization-wide team promoting excellent overall care management of patients admitted to the hospital in either inpatient or observation status. The Case Manager combines their professional knowledge base and experience with critical thinking skills and an organized, team approach to support the delivery of effective and efficient patient care. Accountable for the utilization management, care coordination, and discharge planning for patients within the assigned case load.
Provides patient care, treatment, and services within the scope of their license, certification, registration, and/or assessed competencies. Practice will be in accordance with laws and regulations and will adhere to established policies, procedures and practice guidelines.
- Maintains accountability for facilitating clinical patient progression through a defined plan of care to achieve optimal outcomes.
- Integrates the nursing process (assess, plan, implement and evaluate) and a quality management process (plan, do, check, act) as the framework for decision-making and problem solving.
- Utilizes professional knowledge to facilitate a physician-specific plan of care, ensure appropriate resource utilization, and coordinate utilization review and approval by payers.
- Supports and coordinates discharge planning services.
- Acts as an effective member of an interdisciplinary team in improving quality, service, and financial aspects of overall patient care management.
- Participates in continuous quality improvement teams and activities.
- Participates in supporting the organization’s vision, mission and values and adheres to DeKalb Medical Standards of Behavior.
- Performs other duties as assigned to meet the goals and objectives of DeKalb Medical.
Minimum Education, Experience and Licensure Required:
Skills, Knowledge and Abilities:
Reports to: Lead Care Manager, Manager Care Management
Positions Supervised: Care Management Interns