Schedule

Full time

Shift

Day (United States of America)

Address

900 HOPE WAY

City

ALTAMONTE SPRINGS

State

Florida

Postal Code

32714

Job Description

• Reviews and appeals clinical denials across all service lines system-wide
• Researches account histories, patient encounters, payer portals, and payment records to determine appropriate appeal strategies
• Evaluates denial types including but not limited to charge audit, clinical validation, experimental services, payer policy denials, level of care, NICU, and readmissions
• Executes charge corrections and prepares accounts for rebilling as appropriate
• Collaborates with pre-access, patient financial services, revenue integrity, utilization management, and clinical departments to gather supporting documentation
• Provides reports, education, and training on clinical denial trends and recommended remediation strategies
• Educates stakeholders on proper documentation, payer processes, and policies with a denial prevention focus
• Drafts and submits written and verbal appeals using clear, concise clinical terminology
• Researches root causes, collects supporting documentation, and adjusts accounts based on internal and external findings
• Utilizes multiple IT systems to compile comprehensive clinical and financial information for appeals
• Escalates identified claim issues and trends to appropriate leadership or payer contacts
• Performs other duties as assigned

Knowledge, Skills, and Abilities

• Understanding of charge capture, revenue integrity concepts, and defense of appropriately assigned charges on appeal [Required]
• Extensive understanding of CPT, HCPCS, ICD, UB-04 Revenue Codes, modifiers, billing regulations, and guidelines for government and commercial payers [Required]
• Ability to defend the clinical validation of assigned diagnoses [Required]
• Experience with utilization review and understanding of Inpatient vs. Observation assignment using MCG and InterQual [Required]
• Ability to navigate the electronic medical record, understand services performed, and correlate services to charges [Required]
• Strong critical thinking and problem-solving skills with ability to multi-task and reprioritize in a fast-paced environment [Required]
• Ability and willingness to continuously learn new concepts and skills to navigate the ever-changing reimbursement/denials landscape [Required]
• Self-starter with ability to work independently with limited day-to-day oversight [Required]
• Strong written communication and grammatical skills to craft individualized appeal letters based on patient severity, intensity of service, denial type, and applicable regulations [Required]
• Proficiency in Microsoft Suite applications, specifically Word, Excel, and Outlook [Required]
• Ability to utilize Microsoft Teams for communication, meetings, and video presence [Required]
• Technical proficiency to independently set up computer systems, maintain reliable internet service with backup plan, and troubleshoot technical issues [Required]
• Comfort with interpreting payer contractual language [Required]
• Proficiency with Epic EHR system [Preferred]
• Comfort with interpreting payer contractual language [Preferred]

Education

• Bachelor's of Nursing [Required]

Work Experience

• 2+ years of clinical denials or utilization management experience [Required]
• 3+ years' experience as a Registered Nurse (RN) in an acute clinical setting [Required]
• 1+ year in ICU and/or Medical Surgical Unit [Required]
• 1+ year of demonstrated proficiency in appeals writing for all hospital services. [Required]

Licenses and Certifications

• Registered Nurse (RN) [Required]
• Certified Revenue Cycle Rep (CRCR) [Preferred]

Pay Range

$70,682.60 - $131,480.21