Clinical Appeals Specialist II-Hybrid

Mayo Clinic; Rochester (MN); On-site; USD 88,358 - 123,780; Full time

Benefits offered by this job

Medical plan options

Dental coverage

Vision plan with national network

HSA/FSAs

Job summary

Mayo Clinic in Rochester, MN, is seeking a Registered Nurse to review clinically related denials, assist with payer audits, and prepare appeal submissions. The role requires an active RN license and at least 3 years of nursing experience, with knowledge of ICD-10-CM/PCS coding and payer policies.

This is a hybrid position within 100 miles of Mayo Clinic campuses, including Rochester. Responsibilities include collaboration with revenue cycle, case management, and practice stakeholders to defend

Qualifications

• Associate degree in nursing is required.
• Active RN license is required.
• 3+ years of nursing experience preferred.
• Experience with utilization review, denials and appeals is preferred.

Responsibilities

• Review clinically related denials and payer audits.
• Prepare appeal submissions or audit responses.
• Act as liaison to revenue cycle, case management and practice stakeholders.

Skills

RN license

Clinical documentation

Communication skills

Analytical skills

Microsoft Office

Education

Associates Degree

Tools

Epic

Milliman Care Guidelines

InterQual Criteria

MS Office

Job description

Why Mayo Clinic

Mayo Clinic is top-ranked in more specialties than any other care provider according to U.S. News & World Report. As we work together to put the needs of the patient first, we are also dedicated to our employees, investing in competitive compensation and comprehensive benefit plans– to take care of you and your family, now and in the future. And with continuing education and advancement opportunities at every turn, you can build a long, successful career with Mayo Clinic.

Benefits Highlights

• Medical:Multiple plan options.
• Dental:Delta Dental or reimbursement account for flexible coverage.
• Vision:Affordable plan with national network.
• Pre-Tax Savings:HSA and FSAs for eligible expenses.
• Retirement: Competitive retirement package to secure your future.

Responsibilities

This is a hybrid position and must be located within 100 miles of any of the Mayo Clinic campuses for on-site expectations based on business needs.

Primary duties may include, but are not limited to, responsibility for reviewing assigned clinically related denials, payer audits, and payer correspondence as well as preparation of relevant appeal submission or audit responses. Utilizes clinical expertise and critical thinking in the evaluation of medical records against appropriate criteria and contract requirements and utilizes appropriate communication style to appeal or defend medically denied claims. Is a liaison and resource to revenue cycle, case management and practice stakeholders in defending clinically denied claims and providing relevant feedback to key stakeholders on denial prevention opportunities.

Qualifications

Minimum Education: Associates Degree

Minimum Experience: 3 years of relevant nursing experience

Current active unrestricted RN license.

The preferred applicant will have the following experience: Advanced knowledge of ICD-10-CM/PCS coding conventions, DRG reimbursement methodology, and clinical validation principles, with demonstrated ability to interpret Coding Clinic guidance and Medicare IPPS regulations to support accurate DRG assignment and defend coding-related denials.

Healthcare Financial Management Association (HFMA) Certification Preferred.

CCDS or CDIP Certification Preferred.

Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review, and levels of care criteria. Familiarity with Medicaid and Medicare claims denials and appeals processing and regulatory requirements. Knowledge and use of payer medical policy and Medicare LCD/NCD criteria. Knowledge of billing and coding requirements. Experience utilizing Milliman Care Guidelines and InterQual Criteria. Knowledge of current NCQA/URAC standards. Knowledge and experience applying 2-Midnight Rule Criteria. Knowledge and experience in Epic. Must have the ability to effectively utilize Microsoft Office Suite and possess basic data entry skills. Must possess excellent verbal, written and interpersonal communication skills, and able to balance multiple demands and respond to time constraints. Must have high-level skills in organization as well as problem solving and analytical skills.

**This vacancy is not eligible for sponsorship / we will not sponsor or transfer visas for this position.**

Exemption Status

Exempt

Compensation Detail

$88,358 - $123,780/ year;

Benefits Eligible

Yes

Schedule

Full Time

Hours/Pay Period

80

Schedule Details

Standard Days M-F 8-5

International Assignment

No

Site Description

Just as our reputation has spread beyond our Minnesota roots, so have our locations. Today, our employees are located at our three major campuses in Phoenix/Scottsdale, Arizona, Jacksonville, Florida, Rochester, Minnesota, and at Mayo Clinic Health System campuses throughout Midwestern communities, and at our international locations. Each Mayo Clinic location is a special place where our employees thrive in both their work and personal lives. Learn more about what each unique Mayo Clinic campus has to offer, and where your best fit is.

Equal Opportunity

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, national origin, protected veteran status or disability status. Learn more about the EOE is the Law. Mayo Clinic participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization.