Job Description
Alameda Health System
Summary SUMMARY: The System Utilization Management SUM Inpatient Denial Registered Nurse (RN) is responsible for managing, analyzing, and addressing inpatient claim denials. This role involves collaborating with multidisciplinary teams, payers, and physician advisors to ensure proper documentation and compliance with payer requirements. The Inpatient Denials RN serves as a key resource in identifying trends, educating staff, and improving processes to reduce denial rates and optimize revenue cycle outcomes. DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: Following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification. 1. Review inpatient denials to determine root causes and assess clinical documentation for accuracy and completeness. 2. Evaluate denial data to identify trends and patterns, providing feedback to relevant stakeholders. 3. Expeditiously refer cases to the internal/external Physician Advisor for review of requests that may not meet medical necessity criteria. 4. Review admission orders and documentation to confirm alignment with regulatory requirements and payer guidelines. 5. Collaborate with physician advisors to develop and present compelling cases during peer-to-peer reviews. 6. Ensure compliance with federal, state, and organizational regulations, including Medicare and Medicaid guidelines. 7. Stay informed about CMS Conditions of Participation (COP), payer-specific requirements, and industry standards. 8. Communicate with attending physicians to provide updates and guidance on denial cases. 9. Assist with arranging peer-to-peer discussions between attending physicians and payer representatives when an inpatient denial is received. 10. Work with care coordination, coding, and revenue cycle teams to address documentation gaps and improve denial prevention. 11. Provide regular updates to leadership on denial trends, appeal outcomes, and process improvement opportunities. 12. Maintain detailed records of denial cases, and outcomes in accordance with organizational policies. 13. Access payer portals to seek inpatient authorizations. 14. Generate reports on denial metrics and share insights with leadership to drive performance improvements. 15. Identify and address any gaps in documentation that may affect proper classification or reimbursement. 16. Ensure all denial management activities align with CMS regulations and organizational policies. 17. Stay informed on changes to payer guidelines and communicate updates to relevant teams. 18. Assist with Admission and Continued Stay reviews as directed by leadership. 19. Regularly update bed day tables to reflect accurate data on patient utilization, ensuring alignment with reporting and revenue cycle processes. 20. Maintain continued professional growth and education to meet continuing education requirements. 21. Participate in orientation of fresh staff as requested by the Manager of Utilization Management. 22. Maintains knowledge of current trends and changes in healthcare delivery as it pertains to utilization review (e.g., medical necessity, level of care) by participating in appropriate educational opportunities. (Webinars, conferences, local training, Compass Modules). MINIMUM QUALIFICATIONS: Required Education: BSN from an accredited school of nursing. Preferred Education: Master’s degree in nursing. Required Experience: Minimum three (3) years of experience in Utilization Management or Case Management AND proficiency in applying InterQual Criteria (95% or higher IRR). Required Licenses/Certifications: Proof of successful completion of educational requirements for a Board-Certified Registered Nurse as defined by the State of CA in good standing. Preferred Licenses/Certifications: Certified Case Manager (CCM) or Accredited Case Manager (ACM). Highland General Hospital SYS Utilization Management Full Time Day Nursing FTE: 1 –s-p-m1– By applying, you consent to your information being transmitted by Monster to the Employer, as data controller, through the Employers data processor SonicJobs. See SonicJobs Privacy Policy at https://www.sonicjobs.com/us/privacy-policy and Terms of Use at https://www.sonicjobs.com/us/terms-conditions
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