Clinical Denials Specialist Job at firstsourc, Remote

SzZmaUVxY09rU3VObVV6eEo4STJMRHFKZGc9PQ==
  • firstsourc
  • Remote

Job Description

REMOTE

Schedule: M-F, 8am-4:30pm EST

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.

Job Tags

Remote job, Contract work,

Similar Jobs

Carle Health

Radiation Oncology - Physician Job at Carle Health

Overview: Carle Health is seeking an additional BE/BC Radiation Oncologist to join our growing practice at Carle Health Methodist Hospital in Peoria, Illinois.

Work Staff

Remote/Hybrid, Commercial Litigation Associate (Defense side) Job at Work Staff

 ...country. Our team of experienced recruiters work together to match the best candidates with...  ...Commercial Litigation Associate (Defense side) for our client in Los Angeles, CA. The...  ...Salary - USD $225,000 to $255,000 Full-time Benefits - Full Relocation Assistance... 

Scout HR Team

Class A CDL A Shuttle Driver Position Job Job at Scout HR Team

Class A CDL A Shuttle Driver Position JobWe currently have an excellent opportunity for a shuttle driver to join our team. Operating locally within a 250-mile radius of our terminal locations. Our drivers operate modern, well-maintained tractor/trailers and are home... 

Centinela Hospital Medical Center

Registered Nurse, RN Case Manager Job at Centinela Hospital Medical Center

 ...service and severity of illness. Qualifications EDUCATION, EXPERIENCE, TRAINING # A current California State Registered Nurse (RN) license is required. # Five years acute care nursing experience preferred. # At least one year experience in case management,... 

United Parcel Service of America, Inc.

Security Supervisor Job at United Parcel Service of America, Inc.

 ...experience our rewarding culture, and work with talented teams that help you become better every day. We know what it takes to lead UPS into tomorrowpeople with a unique combination of skill + passion. If you have the qualities and drive to lead yourself or teams, there...