Remote - PFS Denial Nurse Auditor

The PFS Denials Auditor works under the supervision of the manager of PFS Denials. The PFS Denials Auditor is responsible for completing, appealing, tracking, and reporting clinical denial reviews to determine the appropriate actions for post-billing denials. This Individual will combine clinical, financial, and regulatory knowledge and skill to reduce financial risk and exposure caused by payer denials for rendered services. The PFS Denials Auditor has highly developed knowledge and skills in areas of: Medical Necessity, Authorizations, Experimental/Investigational denials, payer audits and filing appeals as well as Government and Non-Government payor requirements with Denial Management.

• Completes clinical review of appropriate post-claim denials; prepares clinical discussion and appeal letters for denied accounts.

• Consults clinical and hospital appeal guidelines; provides appeal direction using payer guidelines to appropriate departments via monthly denials meetings.

• Ensures compliance with all federal, state, and local regulations governing rendered patient services and reimbursement.

• Reviews and analyzes specific audit information and provides education to other caregivers both internal and external to the PFS Denial Management team. Identifies, and initiates clinical and hospital quality improvement initiatives focused on improving both quality indicators and outcomes.

• Responds to all internal and external requests for information, data, and/or education specific to clinical and hospital Denial Management.

• Collaborates with Revenue Cycle, Admissions, Coding, and other departments as needed to answer clinical questions specific to denial management. Seeks consultation from appropriate departments as required to expedite clinical review of potential denials.

• Research industry best practices and recommends process improvements to leadership.

• Participates in the review of workflow processes. Recommends and participates in the implementation of process improvements.

• Recommends policies which support the direction of the Denials Management Team to improve and reduce denials.

• Responsible for other miscellaneous duties assigned by PFS Leadership.

Education

• Degree from an accredited school of practical nursing - Required
  

Work Experience

• 5 Years - Experience in health care as a registered nurse, preferably in revenue cycle - Required

• Excellent understanding of financial and health care strategies - Required
  

Licenses and Certifications

• LPN – Licensed Practical Nurse - State Licensure and/or Compact State Licensure - Licensed Practical Nurse - Required
  

Travel Requirements

• None