Hybrid Job Opportunity

This position requires working in office for the first 90 days and then work 2 days a week in office and 3 days a week work from home

Nuvance Health has a network of convenient hospital and outpatient locations — Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York — plus multiple primary and specialty care physician practices locations.

Summary: The Denials & Appeals RN is responsible for the systemwide retroactive medical necessity review of medical services provided. The position is integral in the revenue cycle on a system level and exists to partner Case Management and the System Business Office to overturn medical necessity clinical denials through the appeal process.

The RN will review and respond to all payer (Medicare, and Medicaid, and commercial) medical necessity clinical denials. The RN will identify trends and responds to promote a reduction in the medical necessity denials. This position is key in revenue recovery and maximization of reimbursement.

Essential Responsibilities:

• Reviews all medical and surgical medical necessity denials retrospectively
• Determines the medical necessity for the appeals by reviewing medical records and utilizing clinical and regulatory guidelines
• Discusses with Medical Director(s) or Physician Advisor (s) as needed to establish the appropriate level of care and/or plan for appeal
• Ensures the submission of appeals to the payers within allotted timeframes to prevent fiscal penalties
• Documents and logs appeal information on relevant tracking systems to provide accurate denial data
• Conducts timely review of appealed cases to maximize the reimbursement
• Maintains compliance with HIPAA regulations and accrediting requirements
• Serves as a subject matter expert for appeal and a resource for the team members
• Coordinates activities and strategies with the Case Management Department, Patient Access, Health Information Management, System Business Office, Managed Care, and Physician Advisors
• Maintains and practices a professional image

Requirements:

• Bachelor’s Degree in nursing
• Current NYS or CT Registered Nurse (RN)
• 3 years’ experience in: acute care Nursing; experience as a Utilization Review Nurse in a payer or acute care setting; and experience in revenue cycle management, preferably in a hospital provider environment
• Knowledge of InterQual and MCG as well as CMS Last Covered Day (LCD)/Non-Covered Day (NCD) documentation
• Ability to work in a team environment and form positive, collaborative relationships with hospital staff, providers, patients, and families
• Must be able to manage multiple competing priorities and maintain calm demeanor in stressful environment

What We Offer:
• Medical, Dental, Vision
• Paid Time Off (PTO)
• 401K
• Life and Disability
• Tuition Reimbursement
• In addition, we provide a range of voluntary benefits!!

Location: Summit-100 Reserve Rd - Hybrid

Work Type: Full-Time

Standard Hours: 40.00

Work Shift: Monday thru Friday from 8am to 4:30 pm.

Pay Range: $40 to $54 hourly depending on experience

EOE, including disability/vets.

We will endeavor to make a reasonable accommodation to the known physical or mental limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this form or to participate in an interview, please contact Human Resources at 203-739-7330 (for reasonable accommodation requests only). Please provide all information requested to assure that you are considered for current or future opportunities.