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Job Description Summary:

The position requires a diverse set of organizational skills, medical chart review and analysis, knowledge of claims appeal process and ability to apply (Interqual, Milliman) practice management guidelines to determine medical necessity and appropriateness of coding and billing. Must have the ability to research complex issues pertaining to Medicare reimbursement and payment policies. This position assists in development, implementation, refinement and reporting of the RAC case management and appeals program. It is accountable for reviewing documentation of clinical care provided, financial outcomes of an assigned population, coordinating clinical documentation, drafting appeal letters and identified for RAC audits and appeals in response to a claims denial from the RAC. He/She works collaboratively with all interdisciplinary staff internal to OhioHealth and also external organizations to achieve timely, cost efficient and effective management of the RAC case management appeals process.

Responsibilities And Duties:

80%
Identifies appropriate patients for RAC case management for the service or area covered. Coordinates multidisciplinary response to RAC denial at any of the 5 levels of appeal for inpatients, outpatients, and OhioHealth owned or managed physician office practices. . Works with physician s who provided care, 2nd level appeal review physicians, RAC Coordinator, RAC department liaisons, Clinical Documentation Specialists, and non-RAC case managers at the designated campus to develop a working knowledge of case and build a successful appeal within stated deadlines. Provides documentation education to physicians, Case Managers and Clinical Documentation Specialists when an area of risk is identified, coordinates hours of work with 1st level physician reviewers and tracks and reports physician reviewer hours for physician reviewer payment purposes. Uses appeal decision making tools to identify cases that should be appealed and documents decisions regarding unappeasable cases using RAC tracking software. Monitors due dates for responses and ensures that documentation and response is sent to the RAC within stated deadlines. Directs and collaborates with multidisciplinary team.
20%
Participates in development, implementation and ongoing evaluation of the RAC case management program. Initiates and contributes to modifications/changes in care giver practice patterns defined by RAC denial and appeal outcomes and improved communication between disciplines. Utilizes RAC software to track and trend issues identified during the appeals process and report findings to Director. Actively participates in RAC program development and quality improvement process to ensure quality outcomes and mitigate financial risk.

Minimum Qualifications:

Associate's Degree (Required)RN - Registered Nurse - Ohio Board of Nursing

Additional Job Description:

RN from an accredited school of Nursing and currently licensed in the State of Ohio. Field of Study: nursing or health related field. Clinical expertise in a care setting with background in case management appeals and denials. in coding guidelines. Computer skills/data entry. Data entry analysis skills. Writing skills. Staff RN Experience . 2- 5 years nursing Experience in specialized nursing area.

Work Shift:

Day

Scheduled Weekly Hours :

40

Department

RC Clinical Audit Appeal Department

Join us!
... if your passion is to work in a caring environment
... if you believe that learning is a life-long process
... if you strive for excellence and want to be among the best in the healthcare industry

Equal Employment Opportunity

OhioHealth is an equal opportunity employer and fully supports and maintains compliance with all state, federal, and local regulations. OhioHealth does not discriminate against associates or applicants because of race, color, genetic information, religion, sex, sexual orientation, gender identity or expression, age, ancestry, national origin, veteran status, military status, pregnancy, disability, marital status, familial status, or other characteristics protected by law. Equal employment is extended to all person in all aspects of the associate-employer relationship including recruitment, hiring, training, promotion, transfer, compensation, discipline, reduction in staff, termination, assignment of benefits, and any other term or condition of employment 

Remote Work Disclaimer:

Positions marked as remote are only eligible for work from Ohio.