RN Appeals Nurse Case Manager - Revenue Cycle

US-GA-Decatur
Employee Type
Full-Time
Department
409030 - Patient Financial Services
Shift
Day
Other Shift
8a-5p
Days of the Week for Employee
Monday - Friday
450 North Candler Street

Overview

Experienced RN Case Manager - Revenue Cycle: DeKalb Medical, North Decatur Campus

 

Full-time Case Manager position currently available for experienced case manager to work in finance/revenue cycle. Previous experience in finance, payer, utilization and appeals in hospital setting is preferred. Duties will include:

  • Monitor insurance denials by running appropriate reports and contacting insurance companies to resolve claims denied for clinical reasons
  • Identify coding or clinical documentation issues and work to correct the errors in a timely manner.
  • Identify problem accounts and escalates as appropriate
  • Update the patient account record to identify actions taken on the account.
  • Work with guarantors to secure payment on account balances outstanding for clinical reasons
  • Writing Appeal Letters for Authorization and Medical Necessity Denials

Must be self-starter with exceptional communication skills both written and oral. Hours are 8a-5p M-F.  Must have active unrestricted RN License, BSN preferred but not required.

 

 

Responsibilities

JOB SUMMARY:

 

The Case Manager functions as a member of both a unit-specific and an organization-wide team promoting excellent overall care management of patients admitted to the hospital in either inpatient or observation status.  The Case Manager combines their professional knowledge base and experience with critical thinking skills and an organized, team approach to support the delivery of effective and efficient patient care. Accountable for the utilization management, care coordination, and discharge planning for patients within the assigned case load.

 

Provides patient care, treatment, and services within the scope of their license, certification, registration, and/or assessed competencies.  Practice will be in accordance with laws and regulations and will adhere to established policies, procedures and practice guidelines.

 

JOB RESPONSIBILTIES:

  1. Maintains accountability for facilitating clinical patient progression through a defined plan of care to achieve optimal outcomes. 
  2. Integrates the nursing process (assess, plan, implement and evaluate) and a quality management process (plan, do, check, act) as the framework for decision-making and problem solving.
  3. Utilizes professional knowledge to facilitate a physician-specific plan of care, ensure appropriate resource utilization, and coordinate utilization review and approval by payers.
  4. Supports and coordinates discharge planning services.
  5. Acts as an effective member of an interdisciplinary team in improving quality, service, and financial aspects of overall patient care management.
  6. Participates in continuous quality improvement teams and activities.
  7. Participates in supporting the organization’s vision, mission and values and adheres to DeKalb Medical Standards of Behavior.
  8. Performs other duties as assigned to meet the goals and objectives of DeKalb Medical.

 

QUALIFICATIONS

Minimum Education, Experience and Licensure Required:

  • Graduate of an accredited school of Nursing
  • Bachelor’s degree in Nursing (BSN) preferred
  • Current Georgia Licensure as a Registered Nurse
  • Minimum of two (2) years recent acute care experience required, with relevant clinical experience in the assigned area
  • Case Management Certification preferred

 

Skills, Knowledge and Abilities:

  • High degree of self motivation and directional initiative.
  • Excellent customer service skills and strong drive to provide compassionate care.
  • Critical thinking skills, decisive judgment and the ability to work with minimal supervision in a fast paced environment.
  • Strong communication skills with ability to effectively communicate technical information to patients and families.
  • Ability to effectively manage multiple tasks and priorities within a fast-paced environment.
  • Ability to collaborate effectively with multidisciplinary healthcare teams.
  • Must be able to perform skills and competencies as defined in orientation checklist and annual departmental competency checklist if applicable.
  • Demonstrates and maintains competencies specific to patient population served.

 

 

REPORTING RELATIONSHIPS:

Reports to: Lead Care Manager, Manager Care Management

Positions Supervised: Care Management Interns

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