Denials Management Clinical Specialist in Altamonte Springs, FL at Adventist Health System

Date Posted: 11/9/2018

Job Snapshot

  • Job Schedule
  • Job Category
  • Date Posted:
  • Job ID:
  • Job Function
  • Travel
    Yes, 50 % of the Time
  • Shift
    1 - Day
  • AHS Zone
    1-Shared Services
  • Organization
    Adventist Health System Corporate Office

Job Description

Work Hours/Shift

Full Time, Monday-Friday

Adventist Health System Corporate Office

Be part of the Adventist Health System family.

Where you work matters. Working here is like being part of a family. Not just with those you serve, but also with your team members. It’s about making a difference, saving lives, and helping others live a fuller one. You’ll be joining a family of tens of thousands of team members who understand that what they do is bigger than healthcare. It is living out our mission to Extend the Healing Ministry of Christ and being there for someone every step of the way-body, mind, and spirit.

This is more than a career. It is a calling.

With hospitals and facilities in 9 states, you’ll have endless opportunities to take your talents, develop your skills, and grow as a professional in a place that truly cares about your success. If you are driven, compassionate, someone who always wants to go above and beyond because you care and believe what you do makes a difference – Adventist Health System is for you.

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.

What 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.
  • Capable of researching underlying root cause, collecting required information or documents, and adjusting the account as necessary. Is comfortable communicating denial root cause and resolution to leadership as needed.
  • Escalates any discrepancies and issues encountered to supervisors in a timely manner. Keeps up to date on department and organization policies and payer regulations.
  • Participates in denials management committees and provides updates on coding related denials trends, issues and remediation plans as needed.
  • Participates in any meetings, phone conferences or webinars as needed to either appeal cases or expand knowledge regarding the appeal process, changing rules and regulations, and understanding the contract language that the facility operates under.
  • 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 for management action.
  • Maintains a positive working relationship with internal staff and external providers, payer representatives and patients and acts in a professional, courteous manner at all times.
  • Performs other duties as assigned by management.
What you will need:
  • Bachelor’s Degree in Nursing
  • Minimum of three (3) years’ experience as Registered Nurse (RN) in an acute clinical setting
  • Current and valid RN license

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