Employment Type:

Full time

Shift:

Day Shift

Description:

Position Summary

The OR Revenue Protection RN is responsible for proactively identifying and mitigating authorization, medical necessity, and reimbursement risks associated with surgical procedures. This role serves as a critical liaison between surgeon offices, Case Management, Operating Room teams, and Revenue Integrity to ensure appropriate authorizations, documentation, and patient status determinations are secured prior to surgery. The OR Revenue Protection RN supports organizational denial prevention efforts and protects revenue through collaboration, education, analysis, and process improvement initiatives.

Responsibilities

• Review procedure change work queues to determine whether newly assigned procedure codes require prior authorization.
• Collaborate with surgeon offices to obtain updated authorizations when procedure changes occur.
• Participate in daily morning and afternoon OR Revenue Protection huddles.
• Prepare surgical accounts for review in advance of next-day procedures.
• Partner with Case Management and Operating Room teams to identify patient status changes that may impact reimbursement.
• Review upcoming surgical procedures for potential medical necessity concerns and ensure supporting documentation is obtained from provider offices.
• Assess authorization, medical necessity, and reimbursement risks associated with scheduled surgical cases.
• Coordinate with provider offices to ensure all required authorizations are obtained prior to surgery.
• Ensure complete and accurate documentation is available to support medical necessity and payer requirements.
• Track, trend, and analyze denial risks, reimbursement vulnerabilities, and revenue protection opportunities.
• Maintain reports and provide data supporting denial prevention and process improvement initiatives.
• Collaborate with Revenue Integrity, providers, and operational leaders to identify and address education needs related to authorization requirements, documentation standards, and medical necessity criteria.
• Provide guidance and education to physicians, provider offices, and operational teams regarding payer requirements, authorization processes, documentation standards, and reimbursement best practices.
• Identify trends and recommend process improvements to reduce denials and strengthen revenue protection strategies.

Success Measures

Success in this role is demonstrated through:

• Reduction in denials related to Inpatient Only (IPO) procedures.
• Decreased procedure change and authorization-related denials.
• Proactive identification and resolution of authorization and medical necessity risks prior to surgery.
• Improved documentation compliance and reimbursement outcomes.
• Strong collaboration across provider offices, Surgical Services, Case Management, and Revenue Integrity teams.
• Enhanced organizational revenue protection and denial prevention performance.

What Makes This Role Unique

• Opportunity to leverage nursing expertise in a revenue protection and denial prevention capacity.
• Direct impact on organizational financial performance through proactive risk identification and mitigation.
• Extensive collaboration with Surgical Services, Revenue Integrity, Case Management, and provider practices.
• Ability to influence operational improvements through education, risk analysis, trend reporting, and cross-functional partnerships.
• Unique blend of clinical knowledge, revenue cycle understanding, and process improvement responsibilities.

Qualifications

Required Qualifications

• Active Registered Nurse (RN) license in good standing in any U.S. state.
• Graduate of an accredited Registered Nursing program.
• Strong clinical assessment and critical thinking skills.
• Excellent communication, organizational, and problem-solving abilities.
• Ability to effectively collaborate with multidisciplinary teams and provider offices.
• Demonstrated ability to manage multiple priorities in a fast-paced healthcare environment.

Preferred Qualifications

• Case Management experience.
• Appeals and denial management experience.
• Revenue Integrity experience.
• Knowledge of healthcare Revenue Cycle operations.
• Experience with utilization review, medical necessity determinations, and payer authorization requirements.
• Experience supporting surgical services, procedural areas, or reimbursement-related workflows.

Pay Range: $74,265.00 - $104,374.40 per year

Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.

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.