Clinical Denials Coordinator

Entity: Owensboro Health Regional Hospital Department: Case Management Work Hours: M-F 8-4:30 Weekend Requirements: N/A 1.0 FTE

Job Summary:

Responsible for managing the initial clinical denials process related to authorizations, notifications, and medical necessity denials for all government and commercial payers for hospital patients. This role involves reviewing and analyzing initial denials, providing education to providers and case managers, and working closely with the physician advisor(s) and other departments to resolve denials and recover payments. The Clinical Denials Coordinator serves as a clinical expert on and ensures compliance with medical necessity criteria, inpatient/observation criteria, and Medicare/Medicaid regulations.

Job Responsibilities:

Reviews and analyzes payer denials to determine the cause and develops strategies for resolution.

Communicates timely with insurance companies, providers, case managers, and other departments to resolve denials and secure payments.

Maintains detailed documentation of all denials, causes, appeal status, and outcomes.

Generates and analyzes reports on denial trends, recovery rates, and other relevant metrics to identify opportunities for improvement.

Provides education and training to case managers, providers, and other healthcare team members on documentation practices and denial prevention strategies.

Collaborates with clinical and administrative teams to develop and implement process improvements to reduce denial rates.

Other duties as assigned.

Skills and Attributes:

Requires critical thinking skills and decisive judgment.

Works under minimal supervision.

Must be able to work in a stressful environment and take appropriate action.

Position Requirements:

Work Experience

A minimum of 3 years' relevant experience required

Education

Associate's degree or higher or Diploma in Nursing required upon hire AND

Bachelor's degree or higher in Nursing required within 5 years of employment in this position

Licensure/Certification/Registration

RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire

Organizational Responsibilities:

Supports Owensboro Health's Mission, Vision, Core Commitments, and business interests. Adheres to all organizational policies and procedures. Executes all tasks and behaves in a manner consistent with a culture of compliance, safety and a high reliability organization.

Additional Job Information:

This job description describes the general nature and level of work required by the position. It is not intended to be an all-inclusive list of qualifications, skills, duties, responsibilities or working conditions of the job. Specific duties and responsibilities consistent with the general nature and level of work described may vary by department and additional related duties may be assigned as needed. Some duties listed may not apply to all employees with this job description.

The job description is subject to change with or without notice, and Management reserves the right to add, modify or remove any qualification or duty. Nothing in this job description changes the existing at-will employment relationship between the Organization and the employee occupying the position.

Standard ADA Settings:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical Demands: (Office Environment)

Standing: 75%

Walking: 75%

Sitting: 50%

Lifting 0-25 lbs: 25%

Lifting 25-75 lbs: 25%

Lifting over 75 lbs: 25%

Carrying 0-25 lbs: 25%

Carrying 25-75 lbs: 25%

Carrying over 75 lbs: 25%

Pushing/Pulling 0-25 lbs: 75%

Pushing/Pulling 25-75 lbs: 50%

Pushing/Pulling over 75 lbs: 50%

Climbing: 50%

Bending/Stooping: 75%

Kneeling: 50%

Crouching/Crawling: 50%

Reaching: 75%

Talking: 75%

Hearing: 75%

Repetitive Foot/Leg Movements: 25%

Repetitive Hand/Arm Movements: 75%

Keyboard Data Entry: 75%

Running: 25%

Vision: Depth Perception: 75%

Vision: Distinguish Color: 75%

Vision: Seeing Far: 75%

Vision: Seeing Near: 75%

Hazardous Drug Risk Exposure:

Risk Level: No-Risk

Owensboro Health Core Commitments

INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.

RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.

TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.

INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.

SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.

EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.