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Denials Management Senior Specialist

Children's Medical Center Type Full time Posted 6/4/2014
Salary - n/a - Starts 10/20/2014
TX - Texas (All) - Dallas Referral - n/a -    

Position Summary

The Denial Management Sr. Specialist supports the Case Management Department by providing clinical data to insurers, evaluating and, if appropriate, contesting payment denials for clinical reasons and collaborating with financial staff on billing and contract issues.  He/she also acts as a resource person for case management staff and other departments on utilization management processes and guidelines in compliance with regulatory and reimbursement requirements.

Essential Duties and Responsibilities

  • Requires in-depth professional knowledge and practical/applied expertise in own discipline and basic knowledge of related disciplines within the broader professional field
  • Has knowledge of best practices and how own area integrates with others; demonstrates awareness of the industry, including regulatory, evolving customer demands, and the factors that differentiate the organization in the market
  • Acts as a resource for colleagues with less experience; may lead projects with manageable risks and resource requirements
  • Solves complex problems and takes a new perspective on existing solutions; exercises judgment based on the analysis of multiple sources of information
  • Impacts a range of customer, operational, project or service activities within  own team and other related teams; works within broad guidelines and policies
  • Works independently, receives minimal guidance
  • Explains difficult or sensitive information; works to build consensus

Ensures that care delivered is medically necessary and high quality. 

Compiles, evaluates and reports statistics to Case Management (CM) Department and utilizes the information to facilitate process improvement activities.        

Collaborates with the healthcare team to develop a plan of care when related to insurance coverage limitations or restrictions. Performs medical record review for appeals and other requests associated with utilization management.

Ensures that resources are used appropriately.Mentor the CM team in the coordination and performance of appropriate utilization reviews.Collaborates and consults with hospital departments on operational components of utilization management; responsibility in identification of appropriate admission and continued stay issues.

Ensures that reimbursement is received for appropriate services. Manages the process to review and, as appropriate, appeals denials received from payors. Responds verbally or in writing to denials by insurance carriers when there is a difference of opinion regarding medical necessity. Maintains database of denials and associated outcomes, capturing financial impact on the. Represents utilization management at various committees, professional organizations within the hospital and outside of the community as necessary or requested.Ensures compliance with utilization management requirements as defined by payors, regulations, legislation, Joint Commission standards and hospital policies and procedures.

Monitors and writes utilization management-related policies and procedures for the Case Management Department incorporating input from the department’s staff.  Maintains concurrent working knowledge of all federal and state and other regulatory guidelines regarding utilization management.  Responsible for providing education for the case management team, medical staff and other appropriate hospital staff.                                                                                                                                                                                     



  • Two-year Associate's degree or equivalent experience required
  • Four-year Bachelor's degree or equivalent experience preferred

Licenses & certifications  

  • RN required
  • Accredited Case Manager (ACM) or Certified Case Manager (CCM) preferred



  • Case Management preferred
  • Denials Mangement preferred
  • Pediatric Nursing preferred

Specific knowledge, skills, and abilities

  • Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
  • Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
  • Develop and use collaborative relationships to facilitate the accomplishment of work goals.
  • Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
  • Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
  • Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
  • Effectively manage one's time and resources to ensure that work is completed efficiently.
  • Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
  • Assimilate and apply new job-related information in a timely manner.
  • Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.

Physical Demands

  • Exerting up to 10lbs. occasionally or negligible weights frequently; sitting most of the time.

Location: Dallas, Texas
Activation Date: Tuesday, June 3, 2014
Expiration Date: Thursday, January 1, 2015
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