Utilization Review - Denial Coordinator

Hours of Work : Days Of Week : Work Shift : Part Time (United States of America) Job Description : Your Job: In conjunction with and in support of the physician-led multidisciplinary care team, assures the appropriate use of clinical resources to accomplish the optimal clinical outcomes. The above is accomplished through the use of medical staff or organizational accepted criteria for determining appropriateness for admission, level of care, and discharge, coordination of patient care through coaching and mentoring care givers, case managing selected cases, and facilitating discharge/transition planning. Participates in ongoing clinical improvement, hospital, and medical staff quality initiatives while supporting the mission, vision, value and strategic goals of Methodist Health System. Your Requirements: • Bachelors of Science degree in Nursing — PREFERRED • Associates Degree in Nursing with insurance or hospital case management experience will be considered. • Current license to practice professional nursing in the state of Texas — REQUIRED for Nursing professionals • Current license from respective agency for non-nurse professionals- PREFERRED • CCM in Case Management — PREFERRED Your Responsibilities: • Assures that appropriate application of internal and external utilization criteria for MMC patients • Acts as resource for staff regarding these criteria and presents education regarding application of the criteria and issuance of HINN letters • Maintains general medical-surgical clinical knowledge; 16 CEUs /year related to med-surg population or Medical Management topics • Identifies opportunities for improved performance to Medical Management staff regarding denial management • Leads orientation of new staff in accordance with departmental guidelines • Identifies methods to avoid denials and reports trends to individual care units and to pertinent nursing leadership staff • Coordinates tracking and monitoring of all activities related to denial/ appeal process within departmental standards and time frames; Identifies reason for denials • Returns appeal requests for denials determined to be technical or those received after the deadline has passed to CBO with explanation • Tracks and analysis’s denials into categories ;reason, day of stay, physician, payer, DRG or MDC, care unit; Incorporates PAD analysis of findings in appropriate manner • Identifies barriers to achievement of departmental goals related to denial management and appropriately reports those suggestions for improvement Methodist Health System is a faith-based organization with a mission to improve and save lives through compassionate, quality healthcare. For nearly a century, Dallas-based Methodist Health System has been a trusted choice for health and wellness. Named one of the fastest-growing health systems in America by Modern Healthcare , Methodist has a network of 12 hospitals (through ownership and affiliation) with nationally recognized medical services, such as a Level I Trauma Center, multi-organ transplantation, Level III Neonatal Intensive Care, neurosurgery, robotic surgical programs, oncology, gastroenterology, and orthopedics, among others. Methodist has more than two dozen clinics located throughout the region, renowned teaching programs, innovative research, and a strong commitment to the community. Our reputation as an award-winning employer shows in the distinctions we’ve earned: Magnet® designations for Methodist Dallas, Methodist Charlton, Methodist Mansfield, and Methodist Richardson Medical Centers 150 Top Places to Work in Healthcare by Becker’s Hospital Review , 2023 Top 10 Military Friendly® Employer, Gold Designation, 2023 Top 10 Military Spouse Friendly® Employer, 2023 Apply Job!