Denials Management RN

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 

The Denials RN plays a critical role in optimizing revenue cycle performance by expertly managing concurrent denials across assigned facilities. This position leverages clinical expertise to conduct thorough root cause analyses, develop effective mitigation plans, and identify process vulnerabilities that lead to denials. By adhering to a standardized approach, the Denials RN ensures accurate billing, promotes financial stewardship, and champions patient advocacy, ultimately contributing to the organization's financial health through sound judgment and critical thinking.

Job responsibilities:

• 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.
• Collects denial metrics and data for the generation of facility and payer specific denial reports.
• 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.
• Collaborates with  various internal departments to gather critical information and  to share denial trends and gaps in process.
• Performs Medicare short stay reviews and validation as assigned.
• Develops, reviews, and recommends policies which support the direction of denial prevention activities.
• Facilitates orientation and onboarding of new staff by acting as a preceptor of newly hired denial RNs.

Minimum:

• California RN license
• Minimum of 3 years clinical work experience as a Registered Nurse.
• Bachelors Degree in Nursing (or other healthcare related field)

We prefer candidates with:

• Minimum 3 years Utilization Management experience
• Denials Management experience
• Care Management certification (CCM or ACM)