Denials Management RN Specialist Remote

AdventHealth Corporate

All the benefits and perks you need for you and your family:

·    Benefits from Day One

·    Career Development

·    Whole Person Wellbeing Resources

·    Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part

of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Shift:   Monday-Friday

Job Location:  Remote

The role you will contribute:

This position is responsible for investigating and appealing post-remit denials for all Inpatient and Outpatient clinical services across the system, as well as review and correct charge errors. The ability to effectively communicate with command of the written English language is crucial for basic job functioning. Understanding revenue cycle processes is necessary in order to effectively evaluate the denial root cause and bring about the best opportunity for fair reimbursement. The Clinical Denial Management Specialist will adhere to the AHS Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies, and will develop and maintain cordial working relationships with team members and stakeholders across the system.

The value you will bring to the team:

• 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 includes but is 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 (MCG or IQ), NICU level of care, readmissions, etc.
• Making appropriate charge corrections for rebilling.
• Collaborates with pre-access, patient financial services, revenue integrity, utilization management and clinical department staff to obtain further patient information to be used in the appeals process if necessary.
• Provide reports, education, and training 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 with a denial prevention strategic focus.
• 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 based on 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 in order to properly process denials 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.

External qualifications-

The expertise and experiences you’ll need to succeed:

·       Bachelor's

The expertise and experiences you’ll need to succeed:

·       Bachelor's

·       1 Related Experience

·       Registered Nurse (RN)

·       Extensive understanding of CPT, HCPCS, ICD, UB-04 Revenue Codes, modifiers, billing, 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

Preferred Qualifications:

·       Master's Preferred

·       Certified Case Manager (CCM) Preferred

·       Certified Clinical Documentation Specialist (CCDS) Preferred

·       Accredited Case Manager (ACM) Preferred