Clinician, Denials Prevention - Remote

Job Purpose The Clinician, Denials Prevention, uses their clinical and administrative skills to analyze denials and appeal outcomes; share opportunities with clients to reduce first pass denials by ensuring proper patient status, authorizations, clinical documentation opportunities, staff education, and collaboration with other departments. Duties & Responsibilities

• Maintain the integrity of information in each appeal produced
• Review a high volume of written appeals to ensure information is medically accurate
• Research payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment
• Make recommendations for workflow revisions to improve efficiency and reduce denials
• Present case studies and recommendations to clients and impacted stakeholders
• Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate
• Identify opportunities for process improvement and actively participate in process improvement initiatives, internally and externally
• Other duties as assigned
• Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Understand and comply with Information Security and HIPAA policies and procedures at all times
• Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties

Qualifications

• Bachelor’s degree in a health-related field; 2 years of experience may be considered in lieu of a degree in addition to the required experience. LPN or RN preferred.
• Two years of recent experience in hospital case management, hospital prior authorization, or utilization management
• Experienced in medical chart review
• Claim-related appeal writing experience preferred
• Experience with medical and insurance terminology, CPT, ICD coding structures, and billing forms
• Experience with MCG and/or InterQual guidelines preferred
• Proficiency in Microsoft Office Suite
• Strong interpersonal skills, ability to communicate well at all levels of the organization
• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
• High level of integrity and dependability with a strong sense of urgency and results oriented
• Excellent written and verbal communication skills required
• Gracious and welcoming personality for customer service interaction

Working Conditions

• Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes.
• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.

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