Clinical Denial Specialist

Franciscan Alliance, Inc.; Oregon; Hybrid; USD 67,000 - 92,000; Full time

Job summary

Franciscan Alliance, Inc. is seeking a Clinical Denial Specialist II to support hospital denial appeals and data-driven improvements. The role requires retrospective review of patient records via EPIC and coordination with clinical teams to address denials.

The position is remote in the United States with standard weekday hours. Qualifications include nursing degrees, an Indiana RN license, denial-related experience, and preferred case management experience.

Qualifications

• Bachelor's degree in Nursing or Associate degree in Nursing with 5 years of nursing experience required.
• Active Indiana RN license required.
• 3 years of denial related experience required.
• 5 years Nursing or Case Management preferred.

Responsibilities

• Develop reports.
• Review governmental contractor's response.
• Identify root causes for potential denials and work with departments and Clinical Documentation Integrity to reduce denials.
• Write and ensure all appeals are filed promptly for Medicare, Medicaid, Managed, and Commercial payors.
• Audit medical documentation for adherence to insurance and CMS guidelines.
• Use inpatient criteria to establish medical necessity letters.

Skills

Nursing experience

Education

Bachelor's degree in Nursing

Associate degree in Nursing

Tools

EPIC

Job description

Work From HomeWork From Home Work From Home, Indiana 46544The Clinical Denial Specialist II functions as a hospital liaison to appeal denied claims for Medicare, Medicaid, Managed and Commercial insurance. This position entails detailed retrospective review via EPIC of patient medical records to analyze and compile data for additional documentation request and claim denials, using trends and patterns identified to support process improvement.

WHO WE ARE

Franciscan Health is a leading healthcare organization dedicated to providing exceptional patient care and promoting health and wellness in our community. Our mission is to ensure that every patient receives the highest quality of care through innovation, compassion, and excellence. With 11 ministries and access points across Indiana, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers who provide compassionate, comprehensive care for our patients and the communities we serve.

WHAT YOU CAN EXPECT

• Schedule: Monday - Friday, 8am - 4:30 pm EST
• Develop reports.
• Review governmental contractor's response.
• Identify underlying root causes for potential denials and works closely with departments and Clinical Documentation Integrity to reduce denials.
• Write and ensure all appeals are filed in a prompt and timely manner for Medicare, Medicaid, Managed, and Commercials Payor.
• Audit medical documentation for adherence to insurance and CMS guidelines relating to inpatient/ observation services, or other denial issues.
• Use knowledge of inpatient criteria to establish medical necessity letters.

QUALIFICATIONS

• Bachelor's degree in Nursing or Associate degree in Nursing with 5 years of nursing experience required
• Active Indiana RN license required
• 3 years of denial related experience required
• 5 years Nursing or Case Management preferred

TRAVEL IS REQUIRED

Never or Rarely

JOB RANGE: Clinical Denials Specialist II: $67,142.40 - $92, 331.20

INCENTIVE:Not Applicable

EQUAL OPPORTUNITY EMPLOYER

It is the policy of Franciscan Alliance to provide equal employment to its employees and qualified applicants for employment as otherwise required by an applicable local, state or Federal law.Franciscan Alliance reserves a Right of Conscience objection in the event local, state or Federal ordinances that violate its values and the free exercise of its religious rights.Franciscan Alliance is committed to equal employment opportunity.Franciscan provides eligible employees with comprehensive benefit offerings. Find an overview on the benefit section of our career site, jobs.franciscanhealth.org .