Remote - PFS Denials Nurse Auditor

The Denials Nurse Auditor works under the supervision of the manager of PFS Denials. The Denials Nurse 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 Denials Nurse 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.
• Researches 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.
• Other duties as assigned.

Education

• Bachelor's Degree - Graduate of school of nursing, BSN - 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

• Registered Nurse (RN) - State Licensure/Or Compact State Licensure - Registered Nurse license by the State of Missouri - Required Upon Hire

Travel Requirements Mosaic Life Care is a health care system in northwest Missouri. With a vision of transforming community health by being a life-care innovator, Mosaic places the holistic needs of patients first by providing the right care at the right time and place, offering high value and quality health care. Mosaic has a wide array of benefits to meet each employee’s individual needs. Our benefits were designed by listening to people just like you. Mosaic also offers several perks with a focus on ensuring our employees feel valued, including concierge services, employee lounge, wellness programs, free covered parking, free on-site and virtual health clinics and many more. When paired with compensation and recognition, it is what continues to make us the employer of choice for employees at any stage of their journey.