Job Description

REMOTE

GENERAL SUMMARY:

The goal of the Clinical Denial Specialist is to successfully manage claim denials related to referral, authorizations, notifications, non-coverage, medical necessity, and other clinically related denials, as assigned. The specialist will review claims and make recommendations for claim resubmission, retro authorization, written appeal or if no action is needed.

The Clinical Denial Specialist will write / submit professionally written appeals including arguments based on the clinical documentation, payer medical policies and contract language. The appeals will be submitted timely and tracked for outcome and trends.

Foundation Knowledge, Skills, and/or Abilities Required: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Duties and Responsibilities:

· Research assigned payer denials (referral, authorization, notification, medical necessity and non-covered services)

· Independently write / submit professional appeal letters in accordance with client and payer policies

· Prepares reports for management review and identifies trends.

· Reviews and understands utilization review and coverage guidelines for multiple payers

· Identify process improvement opportunities

· Monitor denial and appeal outcomes and trends, and report findings to management.

· Ensure all denial management activities comply with federal, state and payer regulations, including HIPAA rerquirements.

Additional Duties and Responsibilities:

· Meet specified goals and objectives as assigned by management on a regular basis.

· Maintain confidentiality of account information at all times.

· Maintain awareness of and actively participate in the Corporate Compliance Program.

· Assist with other projects as assigned by management

· Maintain good working relationships with state and Federal agencies.

· Resolve accounts in a timely manner.

· Maintain a neat and orderly work station

Educational/Vocational/Previous Experience Recommendations:

· Associate’s Degree in a business or healthcare related field.

· Registered Nurse (RN) Certification with experience in care management, utilization review, prior authorization and appeals.

· Electronic Health Record Experience with various platforms (Epic, Cerner, Meditech)

· Knowledge of all insurance payers preferred.

· Proficient PC knowledge and the ability to type 30-40 wpm.

· Professional written and verbal communication skills.

· Capacity to prioritize multiple tasks in a busy work environment.

· Organization and time management skills.

· Capability to present oneself in a courteous and professional manner at all times.

· Ability to stay on task with little or no supervision.

Working Conditions:

· Must be able to sit for extended periods of time.

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