Job Description Up to $10,000 Sign on Bonus for qualified Case Managers! MAIN FUNCTION: The Case Management (denial/prior auth) will review and appeal as appropriate for concurrent and retrospective authorization and denial activities for Arnot Health. Identify, track and trend, record and collect patient accounts denied by payer. Under the direction of the System Director of Care Coordination coordinates data with other Arnot Health departments and third party payers to discourage preventable denials DUTIES AND RESPONSIBILITIES: 1. Retrospectively determines medical necessity and appropriateness of admission and stay in accordance with InterQual Criteria to assist with appeal of denials 2. Maintains a working knowledge of the requirements of 3rd party payers 3. Reviews denials from third party payers obtained from correspondence and or payments. Assists in tracking/trending by payer for denial reason items such as prior authorization, untimely filing, coordination of benefits, services type issues, and insurance or service verification. Identify patterns of common denial errors, types and recurring issues. 4. Facilitates, coordinates and prepares denial appeals working with internal and external customers in a proactive manner to bring satisfactory resolution in coordination with other department staff 5. Relays denial information to appropriate billing clerks and management. 6. Follow up on denial claims using reports to ensure completion of appeal with other department staff 7. Interacts with physicians and other Arnot Health departments in matters of auth/denial review decisions. 8. Maintains a working relationship with Physician Advisor regarding physician issues related to auths/denials. 9. Provide insurance companies with requested patient information as needed. 10. Maintains a working knowledge of programs necessary for denial management (ie: excel, word, QCPR, Sorian, InterQual, eCW) 11. Maintains files and all letters of non-coverage. 12. Tracks and trends denial activity in coordination with other department staff. 13. Maintains a working relationship with Finance and Corporate Compliance officers with regard to denial activity. 14. Is responsible for attending all mandatory annual educational programs as required by the position. 15. Employee understands and demonstrates the importance of satisfying the needs of the customer/patient by interacting with him/her in a friendly and caring way, being attentive to the customer’s needs, both psychologically and physically, and by taking the initiative to maintain communication with the customer in order to provide and secure and pleasant experience with the Arnot Health. 16. It is understood that this lists typical duties for the classification and is not to be considered inclusive of all duties that may be assigned. MEETINGS: Case management staff meetings. Case management staff development meetings. Auth/Denial Management meetings EDUCATION: RN required. EXPERIENCE: NYS licensed Registered Nurse required. Bachelor’s in nursing preferred. Must have proficient writing skills. CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS: BSL preferred PHYSICAL DEMANDS: Routine office job. Light physical effort EXPOSURE CATEGORY: Category III. Tasks that involve no exposure to blood, body fluids or tissues. Category I tasks are not a condition of employment. #LI-TC1 Requirements