[Hiring] Nurse Defense Auditor @UT MD Anderson Cancer Center

Role Description

The Denials Management Coordinator plays a vital role in supporting the organization’s revenue cycle operations by coordinating the review, analysis, and resolution of insurance claim denials to help ensure accurate and timely reimbursement. The Denials Management Coordinator works closely with clinical, financial, coding, billing, and payer teams to support compliant revenue practices and revenue recovery efforts.

• Analyze complex patient accounts, denied claims, audits, and appeals.
• Serve as a liaison between internal stakeholders and third-party payers.
• Identify denial trends, facilitate retrospective approvals, support defense audits, and improve reimbursement outcomes.

Qualifications

• Registered Nurse with a Bachelor’s Degree in Nursing preferred.
• Experience with front-end and back-end insurance appeals, nurse auditing, utilization review, case management, or business office operations.
• Strong knowledge of insurance appeals, medical necessity reviews, nurse defense audit, and case management.

Requirements

• Minimum $89,000 annually – Midpoint $111,000 annually – Maximum $133,000 annually (based on a 40-hour work week).
• Typical work schedule is Monday – Friday 8am – 5pm (must be able to come onsite as needed).
• Work Location: Remote (must be able to come onsite as needed).

Benefits

• Employer-paid medical coverage starting day one for employees working 30+ hours/week, plus optional group dental, vision, life, AD&D, and disability insurance.
• Accruals for PTO and Extended Illness Bank, plus paid holidays, wellness, childcare, and other leave options.
• Tuition Assistance Program after six months of service and access to extensive wellness, fitness, and employee resource groups.
• Defined-benefit pension through the Teachers Retirement System, voluntary retirement plans, and employer-paid life and reduced salary protection programs.

Responsibilities

• Denials Analysis & Appeals:
  • Analyze invoices and patient accounts in the patient accounting system to prepare appeals for third-party payer denials.
  • Utilize Explanation of Benefits (EOB) and Remittance Advices to verify denials and identify appeal opportunities.
  • Review denied services for retrospective approval, continued access needs, retrospective review, and defense audits.
  • Identify and evaluate denial trends that impact reimbursement and revenue cycle performance.
• Payer Communication & Resolution:
  • Contact third-party payers, insurance medical directors, case management, and utilization review teams to request reconsideration and appeals.
  • Provide comprehensive clinical and financial documentation to support appeal requests.
  • Coordinate appeal and audit activities and maintain timely follow-up on appealed or audited claims.
  • Communicate issues affecting future care needs and contract performance to leadership.
• Clinical & Revenue Cycle Collaboration:
  • Collaborate with Case Management and providers to ensure all medical necessity documentation is captured.
  • Serve as a liaison between clinical departments, coding, billing, payer relations, and financial teams.
  • Promote compliant revenue practices and support accurate reimbursement processes.
  • Support resolution strategies for complex denials requiring clinical intervention.
• Documentation & System Management:
  • Update and maintain patient accounting system information, including insurance, demographics, notations, and service codes.
  • Accurately document appeal activities, audit outcomes, and account actions.
  • Maintain confidentiality and follow hospital and departmental policies and procedures.
  • Perform business office responsibilities with minimal supervision while exercising sound judgment.
• Compliance & Professional Knowledge:
  • Demonstrate knowledge of third-party payer claim requirements, UB04, HCFA1500, EOBs, and appeal timelines.
  • Maintain understanding of insurance guidelines related to medical necessity review, including M&R and InterQual.
  • Apply working knowledge of ICD-10 and CPT codes.
  • Stay current on oncology clinical processes, outcomes, clinical trials, and related resources.
  • Contribute ideas and recommendations that improve revenue recovery and team effectiveness.

EDUCATION

• Required: Graduation from an accredited school of nursing.
• Preferred: Bachelor's Degree Nursing.

WORK EXPERIENCE

• Required: 5 years Experience in clinical nursing.
• Required: 1 year Experience in utilization review.
• Preferred: Experience with front-end or back-end appeals, insurance appeals, prior case management, nurse auditing, or business office experience.
• May substitute preferred degree for two years of the five clinical nursing experience.

LICENSES AND CERTIFICATIONS

• Required: RN - Registered Nurse - State Licensure State of Texas Professional Nursing License (RN). Upon Hire.
• Required: BLS - Basic Life Support Upon Hire or CPR - Cardiac Pulmonary Resuscitation Upon Hire.
• Preferred: CM - Case Management Upon Hire.
• Preferred: ACLS - Advanced Cardiac Life Support Certification as required by patient care area. Upon Hire.
• Preferred: PALS - Pediatric Advanced Life Support Certification as required by patient care area. Upon Hire.