CLINICAL APPEALS SPECIALIST Business & Information Technology Hours: M-F 7a - 3:30p Day Shift - Full Time Paygrade/Wages/Salary Info: NE N30 - 29.0000 - 36.4500
REMOTE#position. - in the following states: AL, AZ, AR, GA, FL, IA, IN, IO, KS, LA, MS, MO, MT, NC, OH, OK, SC, SD, TN, TX, UT, VA, WY Position Highlights: Responsible for the administration and coordination of the denials review and appeals management processes that includes denials management, claims recovery, and denial root cause analysis. The Ideal Candidate: Experience in oncology nursing, utilization review, quality management, and/or recent case management and Soarian experience.## Responsibilities: Submit medical necessity appeals electronically and/or mail. Follow up electronically and/or telephonically with payers for claim and appeal status. Make a preliminary determination whether denial can be overturned and if initial or secondary appeals should be submitted. Research and prepare appeal responses to clinical denials. Review of clinical denials including identification of root cause. Resolve clinical denials which include researching and reviewing payer guidelines, writing and submitting appeals with supporting documentation if required. Identifies coding, billing, or reimbursement errors/discrepancies with the denial or aging claim in order to escalate to the denial recovery supervisor. Evaluate denied dollars for both contracting and non-contracting insurance companies; and resolution of reimbursement discrepancies. Resolution of denials for medical necessity, utilization review, pre-certification, authorization, and concurrent review to include writing appeals and responsible for conducting and preparing responses. Track and trend denials issues for escalation to leadership for process improvement. # Credentials and Qualifications: Associate degree required with Healthcare, Finance, or other related field. Bachelors Degree plus a minimum of five (5) years healthcare experience and RN required (OR) #in lieu of# a Bachelor#s degree you must have an Associates degree plus a seven (7) years healthcare experience preferably in Nursing and RN required. **Accommodation: LPN#s currently in the role of Clinical Denial Specialist will be given a specified time frame (2 years) to obtain the RN licensure * #in lieu of# Associate#s, a H.S. Diploma with two (2) years of additional related claims/collection experience maybe considered.