Reviewing and appealing denials for all clinical services across the AH system.
Researching various sources of information to determine appropriateness of appeal vs. other action which includes conducting account history research, navigating patient encounters, reviewing payer website and other resources as applicable, researching charge and payment histories, and any other application necessary to formulate a cohesive and complete clinical appeal or decision regarding other action.
Various types of denial review, appeal, further action which include but are not limited to: charge audit/charge capture denials, charge correction, clinical validation, services deemed experimental, services denied according to various payer policies, inpatient level of care, NICU level of care, readmissions, etc.
Making appropriate charge corrections for rebilling
Collaborates with pre-access, patient financial services, revenue integrity, clinical documentation Improvement, clinical department staff, Coding, physician offices, and utilization review staff to obtain further patient information to be used in the appeals process as necessary.
Provide feedback on identified clinical denial trends and recommended remediation as required or requested by supervisors.
Recommends or educates others on proper documentation, payer processes, and policies in a denial prevention strategic focus as requested.
Able to defend and appeal denied claims via both written and verbal communication in clear and concise arguments/rationale in clinical terms/language.
Capable of researching underlying root cause, collecting required information or documents, and adjusting the account as necessary from all related internal and external information sources.
Able to work in multiple IT solutions at one time to ascertain the complete clinical and financial information required to formulate comprehensive written appeals.
Escalates any discrepancies and issues encountered to supervisors in a timely manner. Keeps up to date on department and organization policies as well as payer and all regulatory and compliance rules and regulations.
Participates in any meetings, phone conferences or webinars as needed to either appeal cases or expand knowledge regarding the appeal process, changing rules and regulations, and understanding payer contract language.
Strives towards meeting and exceeding productivity and quality expectations to align performance with assigned roles and responsibilities. Escalates concerns or difficulties in meeting performance expectations in a timely manner.
Performs other duties as assigned by management.
What You Will Need:
Bachelor’s degree in field such as nursing, management, business
Minimum of three (3) years’ experience as Registered Nurse (RN) in an acute clinical setting, preferably including ICU and ED experience
Current and valid RN license
Education and Experience Preferred:
Advanced degree in any field of study
Experience in charge capture, denial management, utilization review, case management, clinical documentation improvement, revenue integrity, or related field
Knowledge and Skills Required:
Extensive understanding of CPT, HCPCS, ICD, UB-04, LCD/NCD, revenue Codes, modifiers, billing practices, regulations, and guidelines for government and commercial payers
Understanding of charge capture, revenue integrity concepts, and defense of appropriately assigned charges on appeal
Ability to defend the clinical validation of assigned diagnoses
Experience with utilization review and understanding of assignment of Inpatient vs. Observation according to appropriate application of MCG and InterQual
Ability to quickly navigate the electronic medical record, understand services performed, and correlate those services to charges on the bill
Strong critical thinking and problem-solving skills with ability to multi-task or reprioritize quickly in a high productivity, fast paced environment
Ability and willingness to continuously learn new concepts and skills required to navigate ever-changing reimbursement / denials landscape
Self-starter with the ability to work under limited day-to-day oversight
Strong written communication / grammatical skills to quickly craft appeal letters that are each individualized according to patient’s severity of illness, intensity of service, denial type, and resource against which necessitated denial
Proficiency in Microsoft Suite applications, specifically Word, Excel, and Outlook.
Ability to constantly utilize Microsoft Teams to stay in communication with key members, join meetings, and utilize video to maintain presence in the meeting.
Technical proficiency to independently set up computer system including monitors, docking station, keyboard, and ability to maintain reliable internet service along with backup internet plan for outages, and troubleshoot/resolve problems
The Denials Management Clinical Specialist RN is responsible for reviewing and appealing denials for all clinical services across the AH system. Various types of denial review, appeal, and further action include but are not limited to charge audit/charge capture denials, charge correction, clinical validation, services deemed experimental, services denied according to various payer policies, inpatient level of care, NICU level of care, readmissions, etc. The ability to craft appeals demonstrating stellar grammatical skills and sentence structure in a concise and compelling manner, clearly demonstrating how the clinical scenario met the specific requirements against which the denial was generated by the payer, is a continuous expectation. This role will actively participate in meetings via Microsoft Teams on video and collaborate with departmental processes. The Clinical Denial Management Specialist will serve as a resource for all clinical questions and guidance on working clinical denials and will communicate with other departments to ensure accurate and timely claim adjudication as well as adhering to the AHS Compliance Plan and to all rules and regulations of applicable locate, state, and federal agencies/accrediting entities.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.