Staff - Registered Nurse (RN) - Resource - $35-55 per hour

Company: Baylor Scott & White Health
Location: Garland
Posted on: May 28, 2023

Job Description:

Baylor Scott & White Health is seeking a Registered Nurse (RN) Resource for a nursing job in Dallas, Texas. Job Description & Requirements

• Specialty: Resource
• Discipline: RN
• Start Date: ASAP
• Duration: Ongoing
• 36 hours per week
• Shift: 12 hours
• Employment Type: Permanent JOB SUMMARY The Denial Resource Center Registered Nurse (RN) is accountable for Baylor Scott & White Health denial management functions. The Denial Resource Center (DRC) is accountable for receiving claim denials and appealing to payors to promote appropriate reimbursement from payors to BSWH hospitals. The DRC RN manages denials from all payors, including denials for lack of medical necessity, pre-cert, re-cert, billing, coding, and patient status. ESSENTIAL FUNCTIONS OF THE ROLE
  • Receives clinically denied claims from the BSWH Central Business Office, or directly from the payor, and appeals the denied claim through all appropriate levels of appeal as defined by the payor.
  • Reviews the denied patient's medical record to examine the following in order to appeal the denied claim: Appropriate level of care, appropriate admission status, medical necessity for the hospitalization, appropriate application of InterQual criteria, appropriate LOS and discharge planning
  • Reviews and any associated physician office records that may assist with the appeal process and/or regulatory documentation requirements.
  • Engages the attending and consulting physicians as well as the Care Coordination Medical Directors when needed to assist in appeal writing.
  • Performs chart study on quality surveillance and special studies as requested, i.e. Novitas, OIG, CMS probes.
  • Identifies opportunities for and participates in process improvement
  • Identifies denial trends by DRG, type, procedure, etc.
  • Assists leadership in developing medical necessity documentation forms to meet regulatory requirements.
  • Participates in pertinent meetings, including hospital AWO meetings, to split denial trends and activities seen within the DRC with key stakeholders.
  • Documents denial information and appeal findings into the DRC electronic system for research of denial trends and appeal outcomes. KEY SUCCESS FACTORS
    • Knows commercial and government regulations for reimbursement including, but not limited to: InterQual, RAC/MAC, Clinical Policy Bulletins, national and local coverage determinations, CMS admission status requirements, TJC conditions of participation, CMS appeals process, including Administrative Law Judge.
    • Knowledge and expertise of nursing and patient care standards and procedures.
    • Knowledge of laws, rules and regulations; standards and guidelines of certifying and accrediting bodies; hospital and department/unit standards, protocols, policies and procedures governing the provision of nursing care applicable to the area of assignment.
    • Knowledge of medical terminology; methods and practices of health promotion, risk reduction, illness and disease prevention and management; medications and drugs, common dosages, their physical and physiological effects, and possible adverse reactions.
    • Knowledge of medical and professional nursing ethics and patient privacy rights.
    • Must be able to communicate thoughts clearly, both verbally and in writing.
    • Relational skills to interact with a wide-range of constituencies.
    • Must have critical thinking and problem-solving skills.
    • Ability to observe changes in the medical condition of patients and effectively communicate these changes to other nursing staff members and physicians/providers.
    • Ability to provide age-specific, quality, patient-centered care to all patients through the nursing process and standards of nursing practice with care and respect for the diversity of human experience and to develop, evaluate, implement and, as necessary, modify a patient care plan to meet the needs of separate patients.
    • General computer skills, including but not limited to: Microsoft Office, information security, scheduling and payroll systems, electronic medical documentation, and email.
    • ACM or CCM license preferred. BENEFITS Our competitive benefits package includes the following
      • Immediate eligibility for health and welfare benefits
      • 401(k) savings plan with dollar-for-dollar match up to 5%
      • Tuition Reimbursement
      • PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or levelQUALIFICATIONS
        • EDUCATION - Associate's
        • EXPERIENCE - 2 Years of Experience
        • CERTIFICATION/LICENSE/REGISTRATION - Registered Nurse (RN) Recruiter: Alesandra DunnBaylor Scott and White Job ID . Posted job title: Denial Resource Center RN (Hybrid) About Baylor Scott & White Health As the largest not-for-profit health system in the state of Texas, Baylor Scott & White promotes the health and well-being of every individual, family and community it serves. It is committed to making quality care more accessible, convenient and affordable through its integrated delivery network, which includes the Baylor Scott & White Health Plan, Baylor Scott & White Research Institute, the Baylor Scott & White Quality Alliance and its leading digital health platform - MyBSWHealth. Through 51 hospitals and more than 1,100 access points, including flagship academic medical centers in Dallas, Fort Worth and Temple, the system offers the full continuum of care, from primary to award-winning specialty care. Founded as a Christian ministry of healing more than a century ago, Baylor Scott & White today serves more than three million Texans. Benefits
          • Holiday Pay
          • Continuing Education
          • 401k retirement plan
          • Wellness and fitness programs
          • Employee assistance programs
          • Medical benefits
          • Dental benefits
          • Vision benefits
          • Benefits start day 1
          • Life insurance
          • Discount program

Keywords: Baylor Scott & White Health, Garland , Staff - Registered Nurse (RN) - Resource - $35-55 per hour, Healthcare , Garland, Texas