DMS RN/Case Manager

Company Overview:

Apollo Health Street is a leading provider of revenue cycle management solutions to the healthcare industry. Our solutions encompass a diverse range of back-office services that span the hospital revenue cycle work flow - from patient admission, charge capture and claims processing to receivables management. We combine our domain knowledge of revenue cycle management with our proprietary technology and process expertise to assist our clients increase productivity and quality of core services. We deploy award winning business processes, re-engineering methodologies and technology-enabled automation to improve profitability, increase productivity and quality, and reduce cycle times. We provide our solutions to healthcare providers such as hospitals and physician practices and to payers such as insurers and third party administrators. In addition to providing revenue cycle solutions, we also provide information technology and strategic support services to our clients as well as to healthcare information technology companies

Job Purpose:

The DMS RN will review medical records and provide clinical appeal support for medical necessity, authorization and other third party denials.

Essential Duties & Responsibilities:

§          Reviews medical records to evaluate validity of third party denials.

§          Evaluates relative appeal strengths in terms of predicting favorable outcomes

§          Reviews managed care contracts against application of rates, provisions and terms.

§          Reviews applicable timeframes governing the appeal process.

§          Constructs 1^st and 2^nd level appeal by applying clinical rationale to overturn denials.

§          Manages assigned workload of accounts through adherence to payer timeframes and astute record keeping in RCMS.

Minimum Knowledge, Competencies & Qualifications:

§          RN (Licensed).

§          Knowledge of/experience working with managed care contracts.

§          Knowledge of/experience with Interqual and/or Millimen guidelines.

§          Knowledge of government denials (Medicare)

§          Knowledge of ICD-9 and CPT coding.

§          Experience in hospital setting.

§          Knowledge of the utilization review process.

§          Proficiency with MS Office.

§          Excellent oral and written communication skills.