Job Summary: Collaborates closely with the Coordinator, Denial & Appeals regarding the insurance denial and appeals processes within the organization. Generates clinical appeals in response to insurance denials received.
Reports to: Coordinator, Denials & Appeals
Education: AAS degree in Nursing. BS in Nursing preferred.
License/Certification: Current New York State Registered Professional Nurse licensure.
Experience: Minimum 2 years acute care utilization management experience; insurance denials management experience preferred.
Skills: Clinical knowledge of standards of practice for all areas and levels of patient care. Knowledge of all aspects of insurance denial and appeals process inclusive of external appeal and dispute resolution authority issues. Knowledge of reimbursement mechanisms and managed care issues. Knowledge and understanding of industry standard utilization criteria. Knowledge of utilization departmental operations within the acute care setting. Excellent analytical and appeal writing skills.