Clinical Appeals Specialist II - PRN/Supplemental

Mayo Foundation for Medical Education and Research; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare provider is seeking a nursing professional to manage clinically related denials and audits. The role emphasizes critical thinking and clinical expertise, requiring a valid RN license and experience in case management. This per diem position offers flexible hours, primarily remote.

Qualifications

• Minimum 3 years of relevant nursing experience.
• Knowledge of Medicaid and Medicare claims processing.
• Experience in utilization review and case management.

Responsibilities

• Review clinically related denials and payer audits.
• Utilize clinical expertise for medical record evaluations.
• Act as liaison with stakeholders on denied claims.

Skills

Clinical Expertise

Communication Skills

Problem Solving

Analytical Skills

Organizational Skills

Education

Active unrestricted RN license

Healthcare Financial Management Association Certification (Preferred)

Tools

Microsoft Office Suite

Epic

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 andcomprehensive 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

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

Requires minimum 3 years of relevant nursing experience. 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. Current active unrestricted RN license. Healthcare Financial Management Association (HFMA) Certification Preferred.

Exemption Status

Nonexempt

Compensation Detail

$41.65 - $58.34 / hour

Benefits Eligible

No

Hours/Pay Period

.004

Schedule Details

Per diem, variable day shift, Monday – Friday, remote

Weekend Schedule

N/A

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 inE-Verifyand 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.

Recruiter

Tavy Smalls