case manager Evanston, IL
NorthShore University HealthSystem
Full Time
Evanston, IL
53632 - 38062 USD ANNUAL Today
Job description
Denials Case Mgr, CrossCareCont, Glenbrook Hospital - (87256)
Position Highlights:
- Position: Denials Case Manager, Cross Care Continum
- Location: Glenbrook Hospital
- Full Time/Part Time: Full Time
- Hours: 40 Hours per week - M-F 8:30am-5:00pm
- Required Travel: N/A
What you will need:
- License: Current professional Nursing Licensure in the State of IL required
- Education: Graduate of a NLN accredited school of nursing required; BSN strongly preferred
- Certification: BLS/CPR Certification for the Healthcare Provider required
- Experience:
- 3+ years of experience in case management, denial management, utilization review, adjudication, reimbursement or equivalent in a healthcare environment required.
- Knowledge of health care reimbursement models, Medicare, Medicaid and Managed Care federal, state and other regulatory agency rules & regulations required.
- Knowledge of Interqual or MCG criteria.
- Excellent verbal communication and interpersonal skills needed to work in a collaborative practice setting with an interdisciplinary team and to interact effectively with patients, physicians, payers, reviewers and other agencies.
- Ability to make formal presentations to physician office staff, medical staff and others.
- Excellent critical thinking skills to identify and resolve issues and independently review, research, analyze and provide feedback regarding processes that affect payment and contracting.
- Excellent critical thinking skills to identify and resolve issues and independently review, research, analyze and provide feedback regarding processes that affect payment and contracting.
- Organizational skills necessary to work independently, follow through on daily activities, multi-task and effectively manage time and resources.
- The ability to effectively manage workflow through automated processes while being proactive, seeking out process improvements or information to avoid issues and/or reporting issues as soon as identified.
- Experience with Microsoft Office Suite
- Strong computer and data entry skills
The purpose of this job:
This role is responsible for ensuring appropriate payment for delivered services for all payor types, so that revenue capture is optimized. Accountable for managing the appeal process across the NSUHS continuum. Utilizes combined clinical and regulatory knowledge and skills to reduce financial risk and exposure caused by concurrent and retrospective denials of payments for services provided by NSUHS. Coordinates appeals of medical necessity denials in collaboration with case management teams, physicians, health information, revenue cycle teams, compliance, coding and third party payers.This role is responsible for ensuring appropriate payment for delivered services for all payor types, so that revenue capture is optimized. Accountable for managing the appeal process across the NSUHS continuum. Utilizes combined clinical and regulatory knowledge and skills to reduce financial risk and exposure caused by concurrent and retrospective denials of payments for services provided by NSUHS. Coordinates appeals of medical necessity denials in collaboration with case management teams, physicians, health information, revenue cycle teams, compliance, coding and third party payers.
What you will do:
a. Assesses denied claims to ensure timely evaluation and response and makes a determination whether or not the case is eligible for appeal by applying clinical and regulatory knowledge and using established clinical level of care criteria, documentation of medical necessity and appropriateness of status order.
b. Monitors the dashboards to proactively identify denial issues with link to inpatient Continuum Management, care navigators, and third party payers. Recommends process improvements to avoid denials, as needed.
c. Works to minimize third party payer denials. Identifies trends in claim denials and partners with various departments, including business office, pre-service, case management, RAC department and medical audit as deemed necessary, in an effort to provide education and/or corrective action to errors related to admission, charging, coding, documentation or billing.
d. Works with physician advisors and other physician leaders to ensure that they are knowledgeable about the denial process and that their workflows are aligned and impactful.
e. Prioritizes appeals according to filing limitations established by the individual payor contracts.
f. Collaborates with the care management teams to review denials and trends and coordinates the appeal process and writes appeal letters to substantiate the medical necessity for coordinating and appealing clinical denials.
g. Serves as a resource and advocate for patients regarding medical necessity billing issues.
h. Continues the appeal process until the case is overturned, appeal options are exhausted or decision is made to discontinue the process and is responsible for ongoing documentation of denial status in denial software.
i. Provides summary reports on denial/appeal activity and financial risk to appropriate oversight committees.
j. Presents data and provides education as needed to appropriate teams and committees as requested.
k. Serve as expert resource regarding payer guidelines and medical necessity criteria.
l. Maintains current knowledge of Medicare/ Medicare Replacements, Medicaid/ Medicaid Replacements and Managed Care Contract requirements, monitoring Center for Medicare and Medicaid Services (CMS) guidelines and industry changes, including inpatient only procedures. Maintains knowledge of federal, state and other regulatory agency rules and regulations.
NorthShore University HealthSystem (NorthShore) is an integrated healthcare delivery system consistently ranked as a Top 15 Teaching Hospital in the U.S. The NorthShore system, headquartered in Evanston, Ill., includes six award-winning hospitals – Evanston, Glenbrook, Highland Park, Northwest Community Skokie, and Swedish. NorthShore comprises three exemplary physician networks, totaling more than 4,250 doctors across immediate, primary, specialty and complex care; and 170+ office locations and 35+ immediate care centers. NorthShore has an established reputation with more than 17,000 team members system-wide.
NorthShore is committed to excellence in its academic mission and supports teaching and research as the principal teaching affiliate of the University of Chicago Pritzker School of Medicine.
NorthShore was the first health system in Illinois to receive Magnet® designation—the highest, most prestigious honor that demonstrates excellence in nursing and high standards in patient care. The system earned Magnet re-designation in 2019. When you work for NorthShore, you will be part of an organization that encourages its employees to achieve career goals and maximize their professional potential.
At NorthShore University HealthSystem, diversity, equity and inclusion are at the core of our mission to support our team members and patients - irrespective of race, ethnicity, age, gender, sexual orientation or socioeconomic status. We believe that by recognizing and embracing our differences we create an organization that welcomes all to contribute and grow.
We invite all candidates to our team, as we continue to build on the incredible value our diverse talent brings to our organization, our community and our patients.
Please explore our website (www.northshore.org) to better understand how NorthShore delivers on its mission "to preserve and improve human life" through superior clinical care, academic excellence and innovative research.
NorthShore is committed to working with and providing reasonable accommodation to individuals with disabilities. Please refer to the main career page for more information.
EOE: Race/Color/Sex/Sexual Orientation/ Gender Identity/Religion/National Origin/Disability/Vets, VEVRRA Federal Contractor.
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Job Posting: Jun 8, 2023, 1:04:00 PM
About NorthShore University HealthSystem
CEO: Gerald Gallagher
Revenue: $1 to $5 billion (USD)
Size: 10000+ Employees
Type: Nonprofit Organization
Website: www.northshore.org
Year Founded: 1891
NorthShore University HealthSystem
www.northshore.org
Evanston, IL
Gerald Gallagher
$1 to $5 billion (USD)
10000+ Employees
Nonprofit Organization
Health Care Services & Hospitals
1891
