Denial and Appeals RN​/Clinical Resource Management

Position: Denial and Appeals RN / Clinical Resource Management
Location Detail: 1290 Silas Deane Hwy Wethrsfld (10181)
Shift Detail:
Monday through Friday 7a-330pm, no holidays and weekends

Work where every moment matters. Every day, more than 40,000 Hartford Health Care colleagues come to work with one thing in common:
Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut’s most comprehensive healthcare network. The creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole, rather than a single member organization.

With the creation of our new umbrella organization we now have our own identity with a unique payroll, benefits, performance management system, service recognition programs and other common practices across the system.

Department

Description:

Integrated Care Partners (ICP) is a physician-led, clinically integrated health care network whose mission is to assist our members in providing the highest quality care at the most reasonable cost for our patients in the current, rapidly changing medical environment.

Position Summary:

The Denial and Appeals Nurse is an integral part of the Care Management team. Their focus is on the management of the payer denial and appeals process. The Denial and Appeals Nurse is responsible for appealing inappropriate denials through all levels of the appeals process. The Denial and Appeals Nurse is able to work autonomously and swiftly, managing a high volume of complex cases across all HHC system hospitals.

Key Areas of Responsibilities:
Follow standard work processes to manage denials and appeals

Ensure activities are completed within regulatory and payer time frames

Develop and maintain collaborative relationships with internal and external stakeholders as needed to obtain additional information to properly formulate the clinical appeal and to resolve any issues that may arise during the appeals process

Partner with the Medical Director and Physician Advisor staff to compose factually sound appeal letters for denial reconsiderations utilizing clinical documentation and contract language

Maintain all documentation associated with the processing and handling of appeals to comply with regulatory standards and time frames while maintaining an accurate, complete appeals record in the appropriate database

Assist in analysis and documentation of root cause for denials

Provide education to stakeholder groups on findings, analysis and mitigation strategies as needed

Work with multi-disciplinary team to identify denial / appeal trends and supports development of performance improvement strategies in response to identified patterns

Other duties as assigned.

Reports To:

Manager, Clinical Resource Management
Qualifications

Education:

Registered Nurse. Bachelors of Science in Nursing is preferred.

Experience:

Five years of relevant case management, utilization management or managed care experience.

Thorough understanding of Medicare, Medicaid, and Commercial reimbursement methodologies is preferred.

Licensure, Certification, Registration:
Current State of Connecticut RN license is required. CCM (certified case manager), CPUM (certified professional in utilization management), or other relevant certification is preferred.

Knowledge, Skills and Ability Requirements:

Strong interpersonal and written / oral communication skills

Maintains a positive attitude in a fast-paced environment Able to influence and negotiate

Critical thinking, astute assessment and confident in decision making

Knowledge of Interqual, MCG, or equivalent criteria and reimbursement guidelines CT RN license required without restriction, to the extent allowed by State and Federal law.

Use of Microsoft Office including Word, Excel, and Power Point Use of EPIC We take great care of careers.

With locations around the state, Hartford Health Care offers exciting opportunities for career development and growth.  Here, you are part of an organization on the cutting edge – helping to bring new technologies, breakthrough treatments and community education to countless men, women and children.  We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance.  

Every moment matters.  And this is your moment.