Job Description

Employment Type:

Full time

Shift:

Description:

Our Trinity Health Culture: Knows, understands, incorporates & demonstrates our Trinity Health Mission, Values,

Vision, Actions & Promise in behaviors, practices & decisions.

Professional Nursing Practice: Acts independently & appropriately within license, scope of knowledge &

experience in practice area; Continues to evolve with best evidence discoveries; Provides leadership & retains

accountability for delegation, choices, decisions & outcomes; Collaborates with key stakeholders & contributes to

quality & improvement practices & outcomes; Exhibits willingness to take on new & additional responsibilities;

Embraces new ideas & cultural differences while managing competing priorities.

Professional Nursing Process (ANA): Knows, understands, incorporates & demonstrates (document, teach,

coordinate, advocate) standard elements of professional practice: Assess, Diagnose, Outcomes Identification /

Solutions, Plan, Implement, Evaluate.

Professional Development: Participates in own professional development by maintaining required competencies,

licenses & certifications, identifying learning needs & seeking appropriate assistance or educational offerings;

Supports the learning & development of others (e.g., staff, formal learners, patients, families, community).

Compassion, Communication & Stewardship: Incorporates caring process (Caritas), advocacy & appropriate

resource utilization as an essential component of nursing practice through concrete acts, interpersonal

relationships & effective & respectful written, verbal & nonverbal communications.

Environment of Care: Practices in an environmentally safe, professional manner; monitors & initiates corrections

or evidence-based practices, including those for equipment & material resources; Promotes optimum physical &

psychological behaviors; Influences effective, judicious & financially responsible use of resources.

Maintains a working knowledge of applicable federal, state & local laws/regulations, Trinity Health Integrity &

Compliance Program & Code of Conduct, as well as other policies, procedures & guidelines in order to ensure

adherence in a manner that reflects honest, ethical & professional behavior & safe work practices

Position Purpose:

The licensed Registered Nurse (RN) plans & provides professional nursing services & standards of practice in accordance with level of experience & education, state board of nursing & established policies & procedures. The RN integrates the art, science, leadership & knowledge of the nursing clinical practice through relationship centered, compassionate, ethical & respectful direct / indirect healthcare services.

What You Will Do:

• Reviews pre/post service initial denials, securing escalated insurance authorizations, handling escalated medical necessity reviews, and coordinating with Patient Access, Mid-Revenue Cycle and Patient Business Service (PBS) to identify opportunities for revenue optimization and to support denial prevention.
• Works closely with Physician Providers to assure that the proposed intensity of service is in alignment with the severity of illness and accurately documented to support level of care determinations and required authorizations.
• Investigates denials and root causes and tracks and reports trends to remediate issues and assist with internal process improvement.
• Leverages clinical knowledge and standard procedures to ensure timely attention to denials as requested by PBS and assists in the research and application of regulatory policies to support administrative appeals.
• Coordinates denial management processes (i.e., Initial Denials such as administrative/technical accounts, and Operational Write-offs) focusing upon process improvement and resolution follow-up:
• Ensures tracking of initial denials identifying trends and collaborating with other Patient Access and Revenue Cycle colleagues for education and reporting to key stakeholders.

Minimum Qualifications:

• Graduation from an accredited school of nursing. Bachelors degree preferred
• License: Valid Ohio RN license
• Experience: 1-2 years' experience of technical and/clinical denials (i.e., medical necessity, eligibility issues, no authorization), medical terminology, and medical record coding experience (ICD-10, CPT/HCPCS)
• Certification and/or membership in AAPC, AHIMA, HFMA, AAHAM, NAHAM - preferred
• Working knowledge of Epic Prelude and Resolute - preferred
• Knowledge of and experience in case management / utilization management and managed care contracts.- preferred
• Knowledge of insurance and governmental programs, regulations, and billing processes (e.g., Medicare, Medicaid, managed care contracts and coordination of benefits is required.

Position Highlights and Benefits:

• Mount Carmel Health System recognized by Forbes in 2025 as one of America’s Best State Employers.
• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement starting on day one.
• RN to BSN tuition 100% paid at Mount Carmel’s College of Nursing.
• Relocation assistance (geographic and position restrictions apply).
• Employee Referral Rewards program.
• Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day!
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.

Ministry/Facility Information:

Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our five hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohio's largest undergraduate, graduate, and doctor of nursing programs. If you’re seeking a rewarding career where your purpose, passion, and desire to make a difference come alive, we invite you to consider joining our team. Here, care is provided by all of us For All of You!

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.