Care Manager Clinical Denials
Harris Health is a nationally recognized health system comprising three teaching hospitals and an extensive network of ambulatory care centers serving the people of Harris County, Texas, since 1966. Staffed by the faculty, fellows and residents from two nationally ranked medical schools, Baylor College of Medicine and The University of Texas Health Science Center at Houston (UTHealth), Harris Health is the first healthcare system in Houston to receive the prestigious National Committee for Quality Assurance (NCQA) designation for its network of patient-centered medical homes.
Each year, Harris Health provides more than 1.8 million total outpatient visits through its more than 40 ambulatory care facilities. Additionally, Harris Health sees more than 177,000 emergency visits at its Level 1 and Level 3 trauma centers and 35,000 hospital admissions through its two hospitals: Ben Taub and LBJ.
Established by voter referendum to enhance the level of charity care available in the community, Harris Health System has often received national recognition for serving those in need and for its achievements in operational excellence, such as being named to the 2011, 2012, 2013 and 2014 Most Wired Hospitals lists by the American Hospital Association’s Hospitals & Health Networks magazine.
Additionally, Harris Health System is pleased that each of its hospitals — Ben Taub and Lyndon B. Johnson — achieved Pathway to Excellence™ designation by the American Nurses Credentialing Center.
Skills / Requirements
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.
1. Education/Licensure/Specialized Training:
a. Education: Graduation from an accredited school of Nursing; BSN preferred
i. Licensed to practice as RN in the state of Texas
ii. Case Management specialty certification required within two (2) years of employment; Clinical Case Management (CCM) certification preferred
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
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:
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