Job Details:

The Case Appeals Nurse manages the process of appealing clinical denials and reviewing denials to the insurance provider.

RESPONSIBILITIES:

• Must have a good understanding of reimbursement methodologies and terms.
• Must have demonstrated knowledge of industry trends in Managed Care.
• Work requires familiarity working with contracts and payment rules.
• Must have demonstrated expertise in insurance, managed care and federal/ state coverage.
• Work requires a high level of problem solving skills.
• Must have working knowledge of utilization management, case management and process improvement.
• Must have base knowledge of clinical coding and reimbursement and/or claims management.
• Must have clear and concise writing skills.
• Work requires the ability to interpret and execute Bon Secours policies and procedures.

QUALIFICATIONS/REQUIREMENTS:

4 years of direct experience in Denials, Utilization Management, Case Management or any combination preferred. Must have clinical knowledge and be able to interpret hospital medical documentation (ie. EMR). Working knowledge and use of evidenced based guidelines. New York State RN license required.

EDUCATION:

Bachelor's Degree in Nursing or Associate Degree in Nursing with clinical specialty certification, Utilization Management or Case Management experience as noted under experience may substitute degree

OTHER:

If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

About Us:

Good Samaritan Hospital

Good Samaritan Hospital in Suffern, NY, is a 286-bed hospital providing emergency, medical, surgical, obstetrical/gynecological and acute-care services to residents of Rockland and southern Orange counties in New York; and northern Bergen County, NJ. The hospital is home to a recognized cardiovascular program, comprehensive cancer-treatment services, the area’s leading Wound and Hyperbaric Institute and outstanding maternal/child services that includes a Children’s Diagnostic Center. Good Samaritan Hospital also provides social, psychiatric and substance-abuse services and its certified home-care agency supports residents of the Hudson Valley and beyond.