Job Summary:

The Clinical Denial nurse will work with our denials team members and clients to assist in the review of medical records and prepare supporting documentation to overturn denials.  Will also review medical records for accuracy of payment and identifying underpayments and overpayments by verifying billings according to appropriate clinical guidelines.  Assists the VP of Clinical Operations in developing ongoing auditing plan that promotes revenue enhancement and compliance, within the laws and regulations to ensure complete charge capture, correct and timely billing in order to obtain additional reimbursement for Praxis Healthcare Solutions, LLC. Clients’.  Must be able to interact with all levels of management within a hospital.

Duties and Responsibilities (not limited to):

  • Review medical documentation and advise Praxis Healthcare Solutions, LLC attorneys on medical necessity issues concerning length of stay, level of care denials

  • Draft appeals to third-party payers to support payment of patient claims, as appropriate

  • Work with hospital clients to drive improvement on national and state/local publicly-reported case management measures, regulatory alignment, risk measures, focused clinical reporting

  • Provide ongoing training/support to Praxis Healthcare Solutions, LLC non-clinical staff members

  • Work any assigned correspondence related to assigned accounts

  • Research and follow payer specific appeal guidelines for appeal submissions

  • Perform other required duties in a timely, professional, and accurate manner

  • Document all activity taken on an account in the patient account notes

  • Request additional information from patients, medical records, and others upon request from payors

  • Review payer contracts and identify billing or coding issues and request re-bills, secondary billing, or corrected bills as needed

  • Perform special projects and other duties as needed.  Ensure compliance with State and Federal Laws Regulations for Managed Care and other Third Party Payors

 KNOWLEDGE, SKILLS, ABILITIES:

  • Must be able to communicate effectively and professionally with strong attention to details and problem solving both verbally and written.

  • Experience using InterQual criteria or Milliman & Robertson healthcare criteria required
  • Ability to prioritize work and meet deadlines is required

  • Ability to operate common computer systems, utilize hospital collection system and business software is required

  • Intermediate understanding of Managed Care Contracts, Contract Language and Federal and State Requirements

  • Working knowledge of utilization management and case management preferred

  • Working knowledge of charge capture audit processes

  • Advanced business letter writing skills to include correct use of grammar and punctuation

  • Understanding of the revenue cycle process

  • Strong interpersonal skills

  • Above average analytical and critical thinking skills

  • Ability to make sound decisions

  • Has a general understanding of hospital collections, Intermediate knowledge of Managed Care contracts, Contract Language and Federal and State requirements

Education/Experience: 

  • Licensed Registered Nurse

  • 3 to 5 years’ experience in utilization management or case management preferred

  • Experience using InterQual criteria or Milliman & Robertson healthcare criteria required

  • Direct experience in medical chart review for inpatient providers preferred.

  • Knowledge of medical coding (CPT, ICD-9/10, HCPS) and reimbursement guidelines preferred

  • Knowledge of HIPAA laws and requirements required

  • Strong analytical skills and strong proficiency in Microsoft Office Tools

  • Experience in an acute care hospital required

Location:  TX-Plano

Job Type – Full Time – days