Care Manager Clinical Denials

Houston, Texas, JOB SUMMARY: The Care Manager Clinical Denials (CM-CD) is responsible for the management of clinical audits and denials related to inpatient medical necessity and/or level of care, and coding. The CM-CD reviews patient medical records and all other pertinent patient information, and applies clinical and regulatory knowledge, screening criteria and judgment, as well as knowledge of payor requirements and denial reason codes/rationale, to determine why cases are denied and whether an appeal is required. For all inappropriate denials, relevant information is submitted, according to each payor’s appeal timeframes, through denial management tracking software with bi-directional interface with physician advisor appeal coordination and follow-up. The CM-CD serves as liaison between Case Management and physicians/providers. The CM-CD performs departmental audits to validate the accuracy and appropriateness of charges being billed to the patient’s account based on current charging policies and documentation of medical necessity. The CM-CD conducts reviews to meet regulatory requirements (e. g. , TDHSC/Medicare/Medicaid) and participates in preventable readmission initiatives. MINIMUM QUALIFICATIONS: 1. Education/Licensure/Specialized Training: a.

Education:Graduation from an accredited school of Nursing; BSN preferred b. Licensure/Certification: i. Licensed to practice as RN in the state of Texas ii. Certified Case Manager or Certified Clinical Documentation Specialist: Case Management (Clinical Case Management/CCM preferred) or Clinical Documentation (Clinical Documentation Specialist/CCDS) Licensed to practice Professional Nursing in the State of Texas specialty certification required within two (2) years of employment. 2. Work Experience: i. Five (5) years’ experience including: three (3) years clinical role and two (2) years of Case Management, Utilization Management/Denials Management SPECIAL REQUIREMENTS: 1. Communication Skills: Above Average Verbal (Heavy Public Contact) Writing /Composing (Correspondence / Reports) 2. Other Skills: Analytical Medical Terms Mathematics PC Statistical MS Project Word Proc MS Word 3. Advance Training Specialty: Case Management specialty certification within two (2) years of employment.

CCM certification preferred Bachelor’s Degree Major: BSN preferred 4. Work Schedule: Flexible 5. Other Requirements: a. Broad knowledge of healthcare and/or hospital business office practices and principles b. Knowledge of third party payer practices including precertification, filing deadlines, claims processing, coverage issues and referral requirements c. Knowledge and understanding of state and federal rules and regulations related to Medicare and Medicaid, laws regarding confidentiality, compliance, release of information, probate and lien legislation, Fair Debt Collection practices, and insurance regulation d. Effective organizational, planning, scheduling and project management abilities e. Knowledge of general accounting principles f. Transportation and valid driver’s license

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