Clinical Denials Management Specialist

Schedule

Full time

Shift

Day (United States of America)

Location

900 HOPE WAY, ALTAMONTE SPRINGS, Florida 32714

Job Description

Reviews and appeals denials for all clinical services across the system. Researches various sources of information to determine the appropriateness of appeal vs. other action. Conducts account history research, navigates patient encounters, reviews payer websites, and other resources. Researches charge and payment histories to formulate a cohesive and complete clinical appeal or decision regarding other action. Reviews various types of denial, appeal, and further action including charge audit/charge capture denials, charge correction, clinical validation, services deemed experimental, services denied according to various payer policies, inpatient level of care, NICU level of care, readmissions, etc. Makes appropriate charge corrections for rebilling. Collaborates with pre-access, patient financial services, revenue integrity, utilization management, and clinical department staff to obtain further patient information for the appeals process. Provides reports, education, and training on identified clinical denial trends and recommended remediation as required or requested by supervisors. Recommends or educates others on proper documentation, payer processes, and policies with a denial prevention strategic focus. Defends and appeals denied claims via written and verbal communication in clear and concise clinical terms. Researches root causes, collects required information or documents, and adjusts accounts based on internal and external sources. Works in multiple IT solutions to gather complete clinical and financial information for comprehensive written appeals. Other duties as assigned.

Knowledge, Skills, and Abilities

• Extensive understanding of CPT, HCPCS, ICD, UB-04 Revenue Codes, modifiers, billing, regulations and guidelines for government and commercial payers [Required]
• Understanding of charge capture, revenue integrity concepts, and defense of appropriately assigned charges on appeal [Required]
• Ability to defend the clinical validation of assigned diagnoses [Required]
• Experience with utilization review and understanding of assignment of Inpatient vs. Observation according to appropriate application of MCG and InterQual [Required]
• Ability to quickly navigate the electronic medical record, understand services performed, and correlate those services to charges on the bill. [Required]
• Strong critical thinking and problem-solving skills with ability to multi-task or reprioritize quickly in a high productivity, fast paced environment [Required]
• Ability and willingness to continuously learn new concepts and skills required to navigate ever-changing reimbursement/denials landscape [Required]
• Self-starter with the ability to work under limited day-to-day oversight [Required]
• Strong written communication / grammatical skills to quickly craft appeal letters that are each individualized according to patient’s severity of illness, intensity of service, denial type, and resource against which necessitated denial [Required]
• Proficiency in Microsoft Suite applications, specifically Word, Excel, and Outlook [Required]
• Ability to constantly utilize Microsoft Teams to stay in communication with key members, join meetings, and utilize video to maintain presence in the meeting. [Required]
• Technical proficiency to independently set up computer system including monitors, docking station, keyboard, and ability to maintain reliable internet service along with backup internet plan for outages, and troubleshoot / resolve problems [Required]
• Comfort with interpreting payer contractual language [Preferred]

Education

• Bachelor's [Required]
• Master's [Preferred]

Field of Study

• in field such as nursing, management, business (if Bachelor’s degree in non-nursing field, must have at least an Associate’s Degree in Nursing)
• Advanced degree in any field of study

Work Experience

• 1+ icu and/or medical surgical unit or at least one (1) year of demonstrated proficiency in appeals writing for all hospital services [Required]
• 2+ utilization review/utilization management experience of utilizing interqual and/or mcg or appeal experience of at least 2 years utilizing interqual and/or mcg [Required]
• 3+ as registered nurse (rn) in an acute clinical setting [Required]
• Denial management, utilization review, case management, clinical documentation improvement, revenue integrity, or related field [Preferred]

Licenses and Certifications

• Registered Nurse (RN) [Required]
• Certified Case Manager (CCM) [Preferred]
• Certified Clinical Documentation Specialist (CCDS) [Preferred]
• Accredited Case Manager (ACM) [Preferred]

Pay Range

$71,385.60 - $132,787.20