This position pays between $62,500.00 - $79,800.00/ based on experience

The Denials RN Coordinator prepares appeals for clinical and technical claim denials across all client hospital facilities. Job duties include but are not limited to: understanding insurance contract terms, reviewing claim denials and underpayments to determine if additional payment amounts can be expected, analyzing medical records and determining if a member or an Independent Review organization (IRO) appeal is necessary, understanding payer medical policy guidelines, preparing IRO appeal documentation which may include correcting and resubmitting claims, gathering additional information, reviewing medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting provider, member and IRO/ALJ appeals in a timely manner. Knowledge and understanding of ERISA compliance laws, healthcare provider and member's legal rights regarding member appeal and grievance processes. Ensures compliance with HIPAA regulations. In addition, the Denials RN Coordinator will work closely with the Clinical Appeal team and Case Management Department to ensure denial trends and outcomes are communicated in a timely manner. Serves as a mentor and provides necessary training and education to Clinical Denial and Underpayment team members. The Denials RN Coordinator will perform these duties while meeting Ensemble principles, as well as meeting the regulatory compliance requirements.

Essential Job Functions

• Denials RN Coordinator primary responsibility is the review of complex claims and escalating clinical or technical claim denials for potential provider, member level or IRO/ALJ appeal.
• Extensive review of medical records for medical necessity criteria, filing written letters of appeal on denied claims, filing complaints with state Department of Insurance, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner.
• Reviewing claim denials and underpayments to determine if additional payment amounts are expected and identifying trends in payment discrepancies amongst payors.
• Work closely with the Clinical Denial team and Case Management Department to ensure denial trends and outcomes are communicated in a timely manner.
• Acts as a mentor and provides necessary training and education to Clinical Denial and Underpayment team members.
• Performs other duties as assigned.

Legally Required License

Registered Nurse RN

Job Experience

5 to 7 years

Preferred Knowledge, Skills and Abilities

• 4 year/ Bachelors Degree
• 2 years of denials, utilization review, or case management experience strongly preferred
• Must pass typing test of 45 words per minute (error adjusted)
• 5+ Years of experience in:
• Revenue Cycle
• Legal nurse consulting
• Chart audit/review
• Provider relations
• Internal Candidate must have met 100% productivity and 100% Quality Assurance, in the previous 3 months
• Demonstrated advanced usage of AI and the management of teams using AI to lean in to process and technological improvements, to include the exploration, experimentation, and application of AI.
• This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.