Clinical Denials and Appeals Specialist-Full Time- Business Office

Job Description

Under the general supervision of the Director of Revenue Cycle, the Clinical Denials and Appeals Specialist performs advanced level work related to Clinical Denial Management. The Clinical Denials and Appeals Specialist will be responsible for managing clinical denials by conducting a comprehensive review of clinical documentation and formulating a timely and defensible written response based on clinical documentation, evidence based medical necessity criteria, physician documentation and medical policies of the Payor. The Clinical Denials and Appeals Specialist will also communicate identified denial trends and patterns to the Director, UM Department, and HIM Department. This individual will work to review, evaluate and improve the organizations clinical denial and appeal process as well.

Minimum Education

Bachelor's Degree in Nursing or in another Clinical Practice field preferred but not required

Minimum Work Experience

3-5 years in Clinical RN or LPN experience including 2 years of Denial Management, Case Management, or related experience

1-2 years of experience with reimbursement methodologies

Required Skills

Must have experience with InterQual and/ or Milliman Disease Management Ideologies

Candidate with strong coding background would be considered

Required Licenses

Current RN or LPN License preferred

Certification in Clinical Documentation Improvement

Eligible Benefits:

Medical Benefits with EXCELLENT premiums

Paid Life Insurance

Paid Time Off

Bereavement

Tuition Reimbursement

Screening Requirements:

Drug Screen

Tuberculosis Test

Background Check

Physical Exam

Respirator Fit

Current flu vaccination

Our Mission:

To improve the lives of those we serve by providing outstanding care and services through our confident, compassionate and exceptional healthcare professionals

Our Vision:

To be chosen by our community and expanded service region based on proven outcomes as the trusted provider to care for their families, friends and neighbors

Our Values:

Compassion, Competence, Excellence, Respect, Integrity

Full-time