Denials Nurse Specialist

Why ThedaCare?

Living A Life Inspired!

Our new vision at ThedaCare is bold, ambitious, and ignited by a shared passion to provide outstanding care. We are inspired to reinvent health care by becoming a proactive partner in health, enriching the lives of all and creating value in everything we do. Each of us are called to take action in delivering higher standards of care, lower costs and a healthier future for our patients, our families, our communities and our world.

At ThedaCare, our team members are empowered to be the catalyst of change through our values of compassion, excellence, leadership, innovation, and agility. A career means much more than excellent compensation and benefits. Our team members are supported by continued opportunities for learning and development, accessible and transparent leadership, and a commitment to work/life balance. If you’re interested in joining a health care system that is changing the face of care and well-being in our community, we encourage you to explore a future with ThedaCare.

Benefits, with a whole-person approach to wellness –

• Lifestyle Engagement
  • e.g. health coaches, relaxation rooms, health focused apps (Wonder, Ripple), mental health support

• Access & Affordability
  • e.g. minimal or zero copays, team member cost sharing premiums, daycare

About ThedaCare!

The RN Care Manager is responsible for coordination of multiple disciplines and resources to facilitate transition of the patient to the appropriate level on the continuum of care. Develops a plan of care to ensure the highest quality care with the best outcomes for the patient in the most cost-effective manner. Integrates decisions of committees into the operation and activities of the department.

Schedule:

Mon - Fri 8:00am - 5:00pm

Flexible

KEY ACCOUNTABILITIES:

• Utilizes nursing process, evidenced-based practice, and unit-specific competencies to complete an accurate and timely assessment of the patient’s needs, goals, preferences, and resources available.

• Facilitates the development of a plan of care in collaboration with the patient, family, caregiver, and health care team. Determines the appropriate level of care and coordinates the interdisciplinary treatment and plan of care.

• Arranges appropriate and prompt access to care transition needs, primary care providers, physician specialists, and similar services/equipment as necessary.

• Evaluates progress toward the goals/expected outcomes of the plan, facilitates the progression of care, and ensures revisions in response to changes in patient needs and condition. Proactively identifies, communicates, and resolves barriers that impede the progression of care.

• Communicates information effectively to the health care team, patient, caregivers/families, and those involved in the treatment and patient’s care.

• Advocates on behalf of patients/families and caregivers for service access and insurance benefits allowing informed choice within the constraints of regulations, and for the protection of the patient’s health, safety, and rights.

• Evaluates the options available and balances cost and quality to ensure the optimal clinical and financial outcomes.

• Collaborates with multiple disciplines internally and externally to effectively and efficiently identify and provide available community resources/potential partners, and advocates for resolution of gaps in the available resources.

• Collaborates with managers, physicians, medical directors, advisory groups, and treatment teams for issues related to physician practices and best practices for the patient’s plan of care.

QUALIFICATIONS:

• Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) required. ADN candidates must also hold a bachelor’s degree in a related field (e.g., Psychology, Social Work, Health Science, or equivalent). Candidates currently enrolled in a BSN completion program may also be considered.

• Current Wisconsin RN License

• American Heart Association Healthcare Provider Basic Life Support (BLS

• National Certification in Care Management (e.g., CCM or ACM) required within one year of hire for candidates with an ADN.

PHYSICAL DEMANDS:

• Ability to move freely (standing, stooping, walking, bending, pushing, and pulling) and lift up to a maximum of twenty-five (25) pounds without assistance

• Job classification is exposed to blood borne pathogens (blood or bodily fluids) while performing job duties

WORK ENVIRONMENT:

• Climate controlled office setting with daily movement throughout the facility

• Interaction with department members and other healthcare providers

Position requires compliance with department specific competencies.

The Denials Nurse Specialist performs all appeals for clinically related claim denials across ThedaCare. Job duties include, but are not limited to, contacting insurance plans to determine reasons claims were denied, analyzing the claims and determining if appeal is necessary, preparing the appeal materials which may include correcting and resubmitting claims, gathering additional information, including reviews of medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner. In addition, the Denials Nurse Specialist will work closely with the Case Management Department to ensure denial trends and outcomes are communicated in a timely manner. The Denials Nurse Specialist I will perform these duties while meeting the mission and goals of ThedaCare, as well as meeting the regulatory compliance requirements.

320.8Corporate 1818 N. Meade Street - Appleton,WisconsinNo