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Denials Management Clinical Specialist in Maitland, FL at AdventHealth

Date Posted: 5/17/2019

Job Snapshot

  • Job Schedule
  • Location:
    Maitland, FL
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Family
  • Travel
    Yes, 25 % of the Time
  • Shift
    1 - Day
  • Application Zone
    1-Shared Services
  • Organization
    AdventHealth Corporate

Job Description


Clinical Denials Management Specialist AdventHealth Corporate

Location Address: 893 Hope Way Altamonte Springs, Florida 32714

Top Reasons to Work at AdventHealth Corporate

  • Great benefits
  • Immediate Health Insurance Coverage
  • Career growth and advancement potential
Work Hours/Shift:
  • Full-Time, Monday – Friday

You Will Be Responsible For:

  • Reviews and resolve accounts assigned via work list daily as directed by management. Conducts account history research as required, including navigating patient encounters and charts, reviewing the payer website activity, researching charge and payment histories, determining historic account and claim status changes, reviewing case management documentation to determine appropriate course of appeal if applicable. Makes manual updates to case management documentation as needed.
  • 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 and provide reports, education, and training on identified clinical denial trends and recommended remediation.
  • Assists in Medicare Recovery Audit Contractor (RAC) denials and processes each denial following the established framework; assistance with additional audits may be required.
  • Recommends or educates others on proper documentation, payer processes, and policies.
  • Able to defend and appeal denied claims via both written and verbal communication in a clear and concise arguments/rationale in clinical terms/language.

What You Will Need:
  • RN with Bachelor’s Degree in Nursing, Management or related healthcare field.
  • Minimum of three (3) years’ experience as Registered Nurse (RN) in an acute clinical setting
  • Current and valid RN license
  • Knowledge of InterQual and MCG as well as CMS LCD/NCD documentation
  • Extensive understanding of CCI edits, CPT, HCPCS, ICD, UB-04 Revenue Codes, modifiers, billing, regulations and guidelines
  • Technical proficiency within patient accounting system and ZirMed technology; position requires ability to navigate various modules within applicable technologies to perform account research
Job Summary:

Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. This position is responsible for investigating and resolving clinical related denials from third party payers in an effort to prevent lost reimbursement. The position will require experience in case management and utilization review, with a focus on researching and appealing clinical denials. The ability to effectively communicate with third party payer representatives and knowledge of appeal guidelines will be vital to the role. The representative will serve as a resource for all clinical questions and guidance on working clinical denials and will utilize the appropriate tools to communicate with other departments regarding any necessary updates to ensure accurate and timely claim adjudication and maximize reimbursement. They will adhere to the AHS Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies.

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

Location | Organization | Category | Job Function