As an Appeals RN you will review and coordinate utilization issues concurrently and retrospectively related to potential denials from managed care, government payers and third party reviewers. You will also participate in departmental quality improvement activities and committees.
- Coordinates appeals process.
- Sorts, reviews and evaluates cases denied by all payers and determines follow through for first, second and third level appeals within contractual or appropriate timeframes.
- Monitors inpatient denials and assists patients and physicians with management of the appeals process.
- Writes first, second and third level insurance appeal letters.
- Reviews and coordinates utilization issues concurrently and retrospectively related to denials from all payors.
- Maintains data tracking systems and identifies Utilization trends.
- Serves as a resource to all hospital staff related to Utilization Management issues.
- Promotes staff development and education.
- Assesses and monitors of quality issues, and follows-up with Quality Management.
- Collaborates with multiple disciplines to identify utilization issues and determine admission appropriateness when accepting a transfer patient into facility.
- Attends Utilization Management Committee and other staff meetings as required.
- Graduate from an accredited School of Nursing. Bachelors Degree in Nursing, preferred. Must be enrolled in an accredited program within 24 months of employment, if hired after September 1, 2010 and obtain a BSN Degree within five (5) years of employment date.
- Current license to practice as a Registered Professional Nurse in New York State.
- Minimum of three (3) years clinical experience including case management, utilization management, discharge planning; third party payment systems; and appeals and denial processes.
- Keeps abreast of all changes in policies and procedures relating to Utilization Management and Case Management.
Transforming care, optimizing patient satisfaction and creating better patient outcomes are just some of the things our talented team members are doing at North Shore-LIJ each and every day. As a culture committed to providing our customers with the highest quality service, we stand behind our core values: Patients first; Caring; Excellence; Innovation; Integrity and Teamwork. It is our commitment and our culture that sets us apart from others and is the cornerstone of everything we do. Join an organization whose team members are valued, cared for and offered continuous opportunities to grow. Click on the link to learn more about us: www.northshorelij.com/goals
Please note: North Shore-LIJ is a smoke-free environment. Smoking and the use of tobacco products is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises. Free smoking cessation programs and quit medications are offered to team members who wish to quit through the North Shore-LIJ Center for Tobacco Control.