Denials Management RN

Where You’ll Work Dignity Health, one of the nation’s largest health care systems, is a 22-state network of more than 9,000 physicians, 63,000 employees, and 400 care centers, including hospitals, urgent and occupational care, imaging and surgery centers, home health, and primary care clinics. Headquartered in San Francisco, Dignity Health is dedicated to providing compassionate, high-quality, and affordable patient-centered care with special attention to the poor and underserved. For more information, please visit our website at www.dignityhealth.org. You can also follow us on Twitter and Facebook. One Community. One Mission. One California Job Summary and Responsibilities As our Denials Management RN, you will be responsible and accountable for receiving, processing, and documenting all concurrent denials for assigned facilities, providing clinical expertise within the revenue cycle.Every day, you will perform root cause analysis of concurrent denials, formulate and implement plans to address specific causes, and identify process gaps leading to denials. You will document and communicate findings to management, and recommend/provide education in collaboration with your manager. You will follow a standardized approach to managing denials to achieve organizational objectives of financial stewardship and patient advocacy through accurate billing. You will use professional judgment, independent analysis, and critical-thinking skills to apply clinical guidelines, policies, and payer knowledge for the best financial outcome. To be successful in your role, you will strategically manage and resolve concurrent denials, leveraging your clinical expertise to conduct root cause analysis, identify process gaps, and implement effective solutions for assigned facilities. You will demonstrate exceptional analytical skills, meticulous documentation, and a strong commitment to financial stewardship and patient advocacy, all while adhering to organizational values and continuously improving revenue cycle integrity through accurate billing and education. Determines appropriate admit status for concurrently denied hospital stays, using utilization management guidelines, medical necessity criteria, critical thinking skills, and physician advisor review. Identifies denial root cause for each individual concurrent denial. Determines appropriate denial resolution strategy based on individual payer policies. Implements strategies, such as RN reconsideration and peer to peer physician review. Escalates challenging cases and concerning payer trends to Leadership. Documents findings and determinations in electronic medical record or denial software. Job Requirements Required Minimum three (3) years clinical experience as Registered Nurse (RN) California RN license Preferred Bachelors Other Graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN) or related healthcare field 5 years of RN experience Three (3) years utilization management experience Denials management experience Certified Case Manager Accredited Case Manager Apply To This Job