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RN Supervisor, Clinical Medical Appeals (Full-Time, Days)
•30 days ago
| Hours | Full-time, Part-time |
|---|---|
| Location | Olympia, WA Olympia, Washington |
About this job
Providence is calling a Registered Nurse Supervisor, Clinical Medical Appeals for the Care Management Program at Providence St. Peter Hospital in Olympia, WA.
The Supervisor provides oversight of the day-to-day operations for Clinical Medical Appeals staff and specific transition of care activities, such as discharge follow-up phone calls. This position reports to the Providence Southwest Region Director of Care Management.
This is a full-time, 8-hour, dayshift exempt level position.
In this position you will:
* Provide support to the processes of appealing hospital claims which were denied based on medical need.
* Work closely with Providence RBO (Regional Business Office) account representatives and the ORC (One Revenue Cycle) denial team to resolve SWR clinical claim payment issues.
* Supports hospital / medical staff to resolve claim issues, concurrently and retrospectively, with facilitation with insurance carriers, education to prevent denials through clinical and documentation process improvements, and producing trend and detail claim denial reports.
* Review medical records using evidence based medical criteria (e.g. Interqual) to accurately represent the severity of illness. This involves extensive daily record review, interaction with physicians, HIM professionals, leadership, nursing staff, RBO and ORC claim staff along with external representatives for health insurance .
Required qualifications for this position include:
* Graduation from an accredited program of nursing
* Bachelor's of Science Degree in Nursing must be obtained within 3 years of hire (not applicable to those who have 20 or more years of RN experience)
* Licensed as a Registered Nurse
* Three to five years of acute care (hospital) experience
* An in-depth knowledge of clinical issues and patient care practices
* Proficiency in speaking reading, and writing English
* Possess strong team building and conflict management skills
* Demonstrate critical thinking, problem solving and deductive reasoning skills
* Knowledgeable of Pathophysiology and Disease Process
* Knowledge of or willingness to learn utilization review, health insurance concepts, and case management as it relates to health care delivery and compliance/regulatory environment for billing
* Must be able to express self clearly, using clinical terms, for external correspondence
* Must be able to review medical records using evidence based medical criteria (e.g. Interqual) to accurately represent the severity of illness
Preferred qualifications for this position include:
* Bachelor's Degree in Nursing at the time of hire
* RN experience in Critical Care, Telemetry, or Emergency Department
* Knowledge of Windows based software programs
About the hospital you will serve:
Providence St. Peter Hospital is a 390-bed, not-for-profit regional teaching hospital. Located in Olympia, WA, St. Peter offers comprehensive rehabilitation, medical, surgical and behavioral health services. We have been ranked as one of the top 100 hospitals and as one of 10 premier healthcare employers in the nation and have recently achieved the coveted Magnet" recognition from the American Nurses Credentialing Center. Our hospital rests on a 173-acre campus, much of which includes natural forest and preserved wetlands that maintain a healing environment for patients and staff.
The Supervisor provides oversight of the day-to-day operations for Clinical Medical Appeals staff and specific transition of care activities, such as discharge follow-up phone calls. This position reports to the Providence Southwest Region Director of Care Management.
This is a full-time, 8-hour, dayshift exempt level position.
In this position you will:
* Provide support to the processes of appealing hospital claims which were denied based on medical need.
* Work closely with Providence RBO (Regional Business Office) account representatives and the ORC (One Revenue Cycle) denial team to resolve SWR clinical claim payment issues.
* Supports hospital / medical staff to resolve claim issues, concurrently and retrospectively, with facilitation with insurance carriers, education to prevent denials through clinical and documentation process improvements, and producing trend and detail claim denial reports.
* Review medical records using evidence based medical criteria (e.g. Interqual) to accurately represent the severity of illness. This involves extensive daily record review, interaction with physicians, HIM professionals, leadership, nursing staff, RBO and ORC claim staff along with external representatives for health insurance .
Required qualifications for this position include:
* Graduation from an accredited program of nursing
* Bachelor's of Science Degree in Nursing must be obtained within 3 years of hire (not applicable to those who have 20 or more years of RN experience)
* Licensed as a Registered Nurse
* Three to five years of acute care (hospital) experience
* An in-depth knowledge of clinical issues and patient care practices
* Proficiency in speaking reading, and writing English
* Possess strong team building and conflict management skills
* Demonstrate critical thinking, problem solving and deductive reasoning skills
* Knowledgeable of Pathophysiology and Disease Process
* Knowledge of or willingness to learn utilization review, health insurance concepts, and case management as it relates to health care delivery and compliance/regulatory environment for billing
* Must be able to express self clearly, using clinical terms, for external correspondence
* Must be able to review medical records using evidence based medical criteria (e.g. Interqual) to accurately represent the severity of illness
Preferred qualifications for this position include:
* Bachelor's Degree in Nursing at the time of hire
* RN experience in Critical Care, Telemetry, or Emergency Department
* Knowledge of Windows based software programs
About the hospital you will serve:
Providence St. Peter Hospital is a 390-bed, not-for-profit regional teaching hospital. Located in Olympia, WA, St. Peter offers comprehensive rehabilitation, medical, surgical and behavioral health services. We have been ranked as one of the top 100 hospitals and as one of 10 premier healthcare employers in the nation and have recently achieved the coveted Magnet" recognition from the American Nurses Credentialing Center. Our hospital rests on a 173-acre campus, much of which includes natural forest and preserved wetlands that maintain a healing environment for patients and staff.