The Clinical Denials Specialist is responsible for reviewing, gathering and formatting data to be submitted in regards to client medical denials. The position assists in the coordination and integration of data from multiple sources to provide and maintain clinical denials and appeals activity. This role reviews patient medical records to determine why cases are denied and whether an appeal is supported and/or required. The specialist assists in the examination and analysis of new regulations to determine the financial impact on the organization.
1. Perform medical necessity reviews on accounts with financial risk due to unresolved accounts receivable including on denied accounts and accounts with other payment discrepancies.
2. Review all medical and surgical denials and provides a recommendation for responding or not responding to the denials.
3. Appeal payment for services denied by Medicare, Medicaid, and Commercial payers by writing and presenting letters of appeal to Insurance Reviewers, Hearing Officers, and Administrative Law Judge
4. Work with Professional Providers and Hospital Departments to bill under correct admission category and educate on required documentation for the prevention of denials
5. Understand the payer contracts and responds to denials within the constraints of those contracts. Uses information on medical necessity and appropriateness of admission stay in accordance with ISDA screening and utilization of the Medicare inpatient only list in response to the denials.
6. Works with Patient Financial Services and Care Management to understand the requirements of all payors and develop a process to prevent denials from occurring.
7. Provide support and education to the case managers for the concurrent denial process to prevent a denial from happening.
8. Trend data and works with contracting and patient financial services to address some of the denial issues through the contracting process.
9. Identify educational opportunities for the clinicians and unit case managers to proactively and concurrently address denials.
10. Collaborate with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.
11. Collaborate with case managers and assists in response to all pre-certification denials while identifying the issues and providing a proactive appropriate to pre-certification denials management.
12. Serve as a liaison and mentor to the Revenue Cycle Team for questions regarding system-wide processes in clinical denials management.
13. Identifies opportunities for improving processes for collecting, analyzing and communicating performance improvement indicators.
14. Focus on attaining daily productivity standards, recommending new approaches for enhancing performance and productivity when appropriate.
15. Prepare and document fact based clinical summaries/appeals based on health care industry accepted criteria, State/Federal reimbursement guidelines, evidenced based research and predictive determinations to support account resolution and/or litigation; if clinical review does not meet criteria, leverages complication and co-morbidities conditions, major complication and co-morbidities and other pertinent clinical facts to support account resolution.
16. Perform retrospective (post -discharge/ post-service) medical necessity reviews to determine appropriateness of level of care documented and provided using nationally accepted criteria, State and Federal Guidelines, evidenced-based research and predictive determinations.
17. Monitor the progress and resolution of appealed denials, following-up with third party payors where necessary in order to drive claims to resolution.
Minimum Education, Experience and Licensure Required:
· Associate Degree in Nursing
· Five (5) years acute care experience, preferably in medical-surgical or critical care
· Two (2) years recent experience in dispute management, clinical documentation, utilization review and/or case management
· Current, valid RN licensure
Skills, Knowledge and Abilities:
· Proficiency in Microsoft Office products (e.g. Word, PowerPoint, and Excel)
· Demonstrates understanding of medical terminology
· Knowledge of CPT, HCPCS, ICD-10 coding procedures
· Good communications skills, both written and oral
· Knowledge of medical billing and collection practices
· In-depth working knowledge of Government, Commercial and Managed Care insurance carriers in either Utilization Review, Case Management or Appeals
Reports to: Payment Recovery Supervisor
Positions Supervised: None
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
· Minimal amount of standing, stooping/bending and reaching is required.
· Requires working inside, 40 hours per week.
· Majority of time spent sitting at desk.
· Maintains a willingness to cooperate with and be courteous to other hospital personnel, patients and visitors.