Denials Management RN

Virginia Mason Franciscan Health has a rich history of providing exceptional healthcare, dating back to 1891. Building upon a legacy of compassionate care and innovation, our organization has evolved over the years through strategic partnerships and integrations to expand our reach and services across the Puget Sound area.

Today, as Virginia Mason Franciscan Health, we remain deeply committed to healing the whole person – body, mind, and spirit – in the communities we serve. This commitment is strengthened by the diverse expertise and shared values brought together through our growth.

Our dedicated providers offer a full spectrum of health care services, from routine wellness to complex disease management, all grounded in rigorous research and education. Our comprehensive network of 10 hospitals and nearly 300 care sites strategically located across the greater Puget Sound region reflects our ongoing commitment to accessibility and comprehensive care.

We are proud of our pioneering medical advances and numerous awards and accreditations that reflect our dedication to excellence. When you join Virginia Mason Franciscan Health, you become part of a team that delivers top-quality, professional healthcare in modern, well-equipped facilities, and contributes to a legacy of service built on collaboration and shared purpose.

The Denials RN is responsible and accountable for receiving, processing and documenting all concurrent denials for assigned facilities.  The RN has an integral role within the revenue cycle  by providing clinical expertise in the denials management process.

The Denials RN performs a root cause analysis of the concurrent denial, formulates and implements a plan for addressing the specific root cause for that denial, identifies gaps in processes that lead to concurrent denials, documents and communicates findings to management.  Recommends and provides education in collaboration with their manager.

The Denials RN follows a standardized approach to managing denials in order to achieve the organizational objectives of financial stewardship and patient advocacy through accurate billing.

Incumbents will use professional judgment, independent analysis and critical-thinking skills to apply clinical guidelines, policies, and payer knowledge to ensure the best possible financial outcome.

The Denials RN is accountable for demonstrating a strong commitment to promoting quality every day by demonstrating our organizational values of: Compassion, Inclusion, Integrity, Excellence, and Collaboration.

1. Determines appropriate admit status  for concurrently denied hospital stays, using utilization management guidelines, medical necessity criteria, critical thinking skills,  and physician advisor review.
2. Identifies denial root cause for each individual concurrent denial.
3. Determines appropriate denial resolution strategy based on individual payer policies.
4. Implements strategies, such as RN reconsideration and peer to peer physician review. 
5. Escalates challenging cases and concerning payer trends to Leadership.
6. Documents findings and determinations in electronic medical record or denial software.
7. Collects denial metrics and data for the generation of facility and payer specific denial reports.
8. Oversees collection and utilization of operational and benchmarking data to identify gaps in process,  recommend and set targets for improvements; and recommends process improvements to leadership.
9. Collaborates with  various internal departments to gather critical information and  to share denial trends and gaps in process.
10. Performs Medicare short stay reviews and validation as assigned.
11. Develops, reviews, and recommends policies which support the direction of denial prevention activities.
12. Facilitates orientation and onboarding of new staff by acting as a preceptor of newly hired denial RNs.
13. Performs other duties as assigned by the manager.

Required:

• Minimum three (3) years clinical experience as Registered Nurse (RN) required.
• Graduation from an accredited school of nursing.
• Current licensure as a Registered Nurse in the state of Washington (RN-WA)
• BLS required within 3 months of hiring if located within hospital

Preferred:

• Graduate of an accredited school of nursing (Bachelor's Degree in Nursing (BSN)) or related healthcare field. 
• 5 years of RN experience preferred.
• Minimum Three (3) years utilization management experience preferred
• Denials management experience preferred.
• Care Management certification (CCM or ACM) preferred
• Certified Case Manager (CCM), Accredited Case Manager (ACM-RN), or UM Certification preferred