People of the U: Rosalind Williams
Published on Wednesday, October 7, 2020
By: Ruth Cummins, email@example.com
When an insurance company denies the claim of a UMMC patient, Rosalind Williams and her coworkers in Revenue Cycle try to discover why.
Williams scrutinizes many details of a patient’s time at the Medical Center. Where were they treated, and how? Were they hospitalized, and why, and for how long? Why did they receive the medications they were given? Why was their treatment medically necessary?
“I handle appeals for claims that were denied for medical necessity,” said Williams, a registered nurse and clinical appeals coordinator. “We analyze the denials and provide a sound appeal that will possibly overturn the denial by the insurance company. That in turn will create revenue for the hospitals.”
Although Williams doesn’t deal directly with patients, she acts as their liaison. She develops a letter to send to the insurance company for each appeal, gathering the clinical information needed to explain why the patient received the treatment they did.
“We look at the intensity of the stay and the severity of the illness,” Williams said, with an eye toward whether criteria set up by the insurance company is being met. Among facts she might gather: “How sick was the patient when they arrived? Did they have a fever? Was their mental status altered? Did we give the patient fluids? What did we do in order to stabilize them in the Emergency Department before they were admitted?”
She evaluates whether the patient needed to be admitted versus whether they could have been appropriately treated in the ED. “Once a patient is admitted, we look at daily clinicals to see what was done for him,” Williams said.
Williams said that one of the best things about her job is the opportunity it gives her to use her combined experiences gained after working 23 years at UMMC.
“I’ve done a lot of different things,” said Williams, a Clinton resident and mom to two teenaged sons. “I’ve worked in Infection control, as a chemotherapy nurse, as a case manager in pediatric and adult care, as a floor nurse, and in utilization review. This helps me to make decisions on my own. I know how things really work.”
“Rosalind is a wealth of knowledge,” said Grant Stapleton, manager of business operations in Patient Financial Services. “She is responsible for creating and submitting appeals and reconsideration requests to denials we receive from both government and non-Government payors. We receive specific types of denials that require a clinical analysis, and Rosalind is a go-to teammate that we can count on to help build a stronger clinical response to support our cases and appeals with the payors.”
Her job can be very rewarding, Williams said. “Whether it’s $1,000 or $300,000, when we can show that we did what we were supposed to do, both the Medical Center and the patient benefit. The patient doesn’t have to have that bill.”
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