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.
a. Education: Graduation from an accredited school of Nursing; BSN preferred b. Licensure/Certification: i. Licensed to practice as RN in the state of Texas ii. Case Management specialty certification required within two (2) years of employment; Clinical Case Management (CCM) certification preferred 2. Work Experience: i. Five (5) years' experience including: three (3) years clinical role and two (2) years of Case Management, Utilization Management/Denials Management
1. Communication Skills: Above Average Verbal (Heavy Public Contact) Writing /Composing (Correspondence / Reports)
2. Other Skills: Analytical Medical Terms Mathematics PC Statistical MS Project Word Proc MS Word
3. Advance Training Specialty: Case Management specialty certification within two (2) years of employment. CCM certification preferred Bachelor's Degree Major: BSN preferred
4. Work Schedule: Flexible
5. Other Requirements: a. Broad knowledge of healthcare and/or hospital business office practices and principles b. Knowledge of third party payer practices including precertification, filing deadlines, claims processing, coverage issues and referral requirements c. 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 d. Effective organizational, planning, scheduling and project management abilities e. Knowledge of general accounting principles f. Transportation and valid driver's license
The Harris Health System is a fully integrated healthcare system that cares for all residents of Harris County, Texas. We are the first accredited healthcare institution in Harris County to be designated by the National Committee for Quality Assurance as a Patient-Centered Medical Home, and are one of the largest systems in the country to achieve the quality standard. Our system includes 23 community health centers, five school-based clinics, a dental center and dialysis center, mobile health units, a rehabilitation and specialty hospital and two full-service hospitals.Ben Taub Hospital is a world renowned Level I Trauma Center with 586 licensed acute-care beds and provides a wide range of specialty care outpatient services. Lyndon B. Johnson Hospital is a 328 licensed bed acute-care hospital with a newly expanded Level III trauma center and a distinguished regional center for neonatal intensive care for high-risk deliveries.Harris Health is a teaching system for Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth). We train the next generation of healthcare providers on the latest medical procedures and technological breakthroughs.With... our fully integrated electronic medical records system, we offer patients the convenience and assurance that their medical history is accurate, safe and available when and where it is needed. Our Medical Home designation ensures that we offer a full range of preventive, specialty and acute care services for the entire family.