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Requisition #: 450823

Location: 3910 Keswick Rd, Baltimore, MD 21211

Shift:

Full Time (40 hours)

Day Shift, 8:00 am - 4:30 pm

Exempt

Position Summary:

Under general supervision of the Director, Revenue Cycle Management and/or Revenue Cycle Manager, Appeals and Denials, the Sr. Appeals Nurse Specialist performs activities to ensure appropriate financial remuneration for inpatient services from third party payers. The position provides a vital link between Patient Accounting, Utilization Management, and Insurance Companies. The individual will be responsible for tracking denied inpatient claims, work with the Appeals Specialist, the Office of Managed Care, payers, outside law firms, and other sources to overturn denials on appeal and be an integral part of the effort to obtain payment for services.

Critical to this position is the ability to multitask. The individual must have organizational and analytical skills. The individual must have the ability to analyze and trend data to identify sources of payment denials and identify ways to improve internal processes to reduce denials. The Senior Appeals Nurse Specialist must be able to work with the Appeals Coordinators, Utilization Management, department administrators, and various billing areas to design processes to minimize denials, to appeal denied claims and track success of both efforts. The Senior Appeals Nurse Specialist must be able to compile reports as needed to track appeal results.

The Senior Appeals Nurse Specialist works as team member, positively accepts change throughout the Health System while establishing relationships at all facilities, and be familiar with each institution’s computer environment and payer contracts as needed.

Education:

Baccalaureate degree, or associate degree, or diploma in nursing from an accredited School of Nursing.

Work Experience:

• Five or more years related experience in health care, health insurance industry, healthcare billing, or Nursing experience in acute care setting
• Demonstrated proficiency in developing and utilizing spreadsheets, graphics and word processing.
• A minimum of four years of experience in nursing in an acute care setting.

Licensure/Certification:

Requires current registered nurse licensure in the State of Maryland

Knowledge/Skills:

• Requires detailed working knowledge of medical terminology, anatomy and physiology, surgical procedures and basic disease processes.
• Advanced knowledge and use of Microsoft Office.
• Advanced knowledge of medical and legal terminology.
• Significant experience in claims processing, third party billing, patient accounts management required.
• Third party payer claims processing and denials knowledge helpful.
• Strong background in appealing administrative denials and medical necessity denials with third party payers at various levels.
• In-depth knowledge of state and federal appeals regulations and statutes required.
• Requires substantial knowledge of standard Utilization Management criteria, broad based clinical knowledge, familiarity with critical pathways, current regulatory requirements, and legislation with respect to third party payers and payer practice patterns.
• Advanced knowledge of database systems, billing applications, and reporting mechanisms.
• Experience in data analysis and report production.
• Current knowledge of third party reimbursement and admitting procedures.
• Knowledge of JHH-specific contractual agreements, required.
• Solid understanding and experience with Milliman Care Guidelines.
• Familiarity with medical records and charting practices is necessary.
• Will serve as a liaison with third party payers in order to establish sound working relationships to negotiate settlement of denied claims.
• Displays judgment in reviewing records to determine appropriate resolution.
• Analysis and trending of statistical data in order to target sources of denial.
• Formulates action plans for denial resolution in conjunction with various departments.
• Possesses excellent interpersonal and both written and verbal communication skills necessary to gather and exchange data (both internal and external) with key professionals.
• Ability to fully review and analyze contracts.
• Possesses a strong analytical ability in order to gather data and decide on conformity based on predetermined criteria.
• Excellent interpersonal skills to handle sensitive and confidential information.
• Work with Utilization Management, department administrators and patient accounting to design systems to minimize denials, to appeal denied claims and track success of both efforts.
• Work requires extreme attention to detail and requires mental/visual acuity.
• Must be able to successfully facilitate communication cross-departmentally concerning appeals and overturn of denials and third party payer issues
• Must professionally interact with other departments, PI/UM, Legal, and financial departments.

Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.

Johns Hopkins Health System and its affiliates are drug-free workplace employers.