Registered Nurse Denial Appeals - Denials Management in Michigan, Grand Blanc chez McLaren Health Care Corp

McLaren Health Care is a fully integrated health network committed to quality, evidence-based patient care with locations in Michigan and Indiana. The McLaren system includes 13 hospitals in Michigan, ambulatory surgery centers, imaging centers, a primary and specialty care physician network, commercial and Medicaid HMOs, home health, infusion and hospice providers, pharmacy services, a clinical laboratory network and a wholly owned medical malpractice insurance company. McLaren operates Michigan’s largest network of cancer centers and providers, anchored by the Karmanos Cancer Institute, one of only 53 National Cancer Institute-designated comprehensive cancer centers in the U.S.

Position Summary: Responsible for coordinating the appeals process for third party payer denials, primarily RAC-related activities and commercial appeals beyond the first level, requiring complex clinical review and appeal letter writing. Responsible for collecting, analyzing, and reporting clinical risk factors for level of care discrepancies. Supports the overall quality, completeness of clinical documentation, and intensity of service application during the appeal process to ensure proper reimbursement is achieved.

Essential Functions and Responsibilities as Assigned:

1. Conducts patient medical record reviews and utilizes clinical knowledge to determine why cases are denied and whether an appeal is required. Confers with physician and management when needed, regarding appeal status.
2. Writes appeal letters, when indicated, pertaining to RAC/3^rd party payers’ disputes/overpayments. Appeal letters will include compelling factual argument and submit to insurance payer requesting timely payment for services.
3. Utilizes pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments.
4. Prepares convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing reference and/or regulatory arguments. Prepares case feedback and provides for review.
5. Communicates and collaborates with physicians, other team members, payers, and administrators regarding denial and appeals cases reviews and process.
6. Maintains accurate complete documentation of all retrospective appeals and corresponding cases information. Enters and maintains data in case management software (i.e., Veracity, Optum, Cerner, etc.).
7. Maintains a knowledge of the appeal processes, requirements of payers, and applicable CMS rules and billing regulations related to Medicare, Medicaid, and commercial insurance.
8. Educates health team colleagues about complex clinical appeals, utilization review, including role, responsibilities tools, and methodologies.
9. Ensures compliance with HIPAA regulations, to include confidentiality, as required.
10. Performs other related duties as required and directed.

McLaren Health Care is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sexual orientation, gender identification, age, sex, marital status, national origin, disability, genetic information, height or weight, protected veteran or other classification protected by law.