Job Summary

The Care Manager Clinical Denials (CM-CD) is responsible for the management of clinical audits and denials related to inpatient medical necessity and/or level of care, and coding. The CM-CD reviews patient medical records and all other pertinent patient information, and applies clinical and regulatory knowledge, screening criteria and judgment, as well as knowledge of payor requirements and denial reason codes/rationale, to determine why cases are denied and whether an appeal is required. For all inappropriate denials, relevant information is submitted, according to each payor's appeal timeframes, through denial management tracking software with bi-directional interface with physician advisor appeal coordination and follow-up.

The CM-CD serves as liaison between Case Management and physicians/providers. The CM-CD performs departmental audits to validate the accuracy and appropriateness of charges being billed to the patient's account based on current charging policies and documentation of medical necessity. The CM- CD conducts reviews to meet regulatory requirements (e.g., TDHSC/Medicare/Medicaid) and participates in preventable readmission initiatives.

Minimum Qualifications

Degrees:
- Bachelor of Science in Nursing (Preferred)
- Diploma in Nursing

Licenses & Certifications:
- Registered Nurse: Licensed to practice Professional Nursing in the State of Texas.
- Certified Case Manager (CCM) OR Certified Clinical Documentation Specialist (CCDS) OR Accredited Case Manager-RN (ACR) specialty certification required within 2 years of employment.

Work Experience:
- Five (5) years' experience including: three (3) years clinical role and two (2) years of Case Management, Utilization Management/Denials Management

Communication Skills:
- Above Average Verbal Communication (Heavy Public Contact)
- Writing/ Correspondence
- Writing/ Reports

Proficiencies:
- MS Word
- PC

Job Attributes

Knowledge/Skills/Abilities:
- Analytical Abilities
- Mathematics
- Medical Terminology Knowledge
- Statistical Knowledge and Abilities

Work Schedule:
- Flexible

Other Special Requirements

Other Requirements:

- Broad knowledge of healthcare and/or hospital business office practices and principles
- Knowledge of third-party payer practices including precertification, filing deadlines, claims processing, coverage issues and referral requirements
- Knowledge and understanding of state and federal rules and regulations related to Medicare and Medicaid, laws regarding confidentiality, compliance, release of information, probate and lien legislation, Fair Debt Collection practices, and insurance regulation
- Effective organizational, planning, scheduling and project management abilities
- Knowledge of general accounting principles
- Transportation