Clinical Denials Management Specialist

AdventHealth

Florida

On-site

USD 71,000 - 133,000

Full time

25 hours ago

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Benefits offered by this job

Medical, Dental, Vision Insurance

Paid Time Off from Day One

403-B Retirement Plan

4 Weeks 100% Paid Parental Leave

Career Development

Whole Person Well-being Resources

Mental Health Resources and Support

Pet Benefits

Job summary

AdventHealth in Florida is seeking an experienced Registered Nurse to review and appeal denials for clinical services across the system. You will research payer policies, charge histories, and determine appropriate actions, collaborating with pre-access, patient financial services, revenue integrity, and clinical departments.

The role requires RN licensure, strong documentation skills, and expertise in CPT/ICD/HCPCS coding, utilization review, and appeal strategy.

Qualifications

Extensive understanding of CPT, HCPCS, ICD, UB-04 and payer policies.
Ability to defend clinical validation of diagnoses and appeals.
Experience with utilization review and determination of inpatient vs observation.

Responsibilities

Review and appeal denials for clinical services across the system.
Research payer policies and charge histories to support appeals.
Collaborate with patient financial services and clinical staff to obtain necessary information for appeals.

Skills

CPT/HCPCS/ICD knowledge

Regulatory and payer rules

MS Word/Excel/Outlook

MS Teams proficiency

EMR navigation

Education

Bachelor's degree

Master's degree

Tools

InterQual/MCG references

Job description

Our Promise To You

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that

Our Promise To You

All the benefits and perks you need for you and your family:

Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance
Paid Time Off from Day One
403-B Retirement Plan
4 Weeks 100% Paid Parental Leave
Career Development
Whole Person Well-being Resources
Mental Health Resources and Support
Pet Benefits

Schedule

Full time

Shift

Day (United States of America)

Address

900 HOPE WAY

City

ALTAMONTE SPRINGS

State

Florida

Postal Code

32714

Job Description

Reviews and appeals denials for all clinical services across the system. Researches various sources of information to determine the appropriateness of appeal vs. other action. Conducts account history research, navigates patient encounters, reviews payer websites, and other resources. Researches charge and payment histories to formulate a cohesive and complete clinical appeal or decision regarding other action. Reviews various types of denial, appeal, and further action including charge audit/charge capture denials, charge correction, clinical validation, services deemed experimental, services denied according to various payer policies, inpatient level of care, NICU level of care, readmissions, etc. Makes appropriate charge corrections for rebilling. Collaborates with pre-access, patient financial services, revenue integrity, utilization management, and clinical department staff to obtain further patient information for the appeals process. Provides reports, education, and training on identified clinical denial trends and recommended remediation as required or requested by supervisors. Recommends or educates others on proper documentation, payer processes, and policies with a denial prevention strategic focus. Defends and appeals denied claims via written and verbal communication in clear and concise clinical terms. Researches root causes, collects required information or documents, and adjusts accounts based on internal and external sources. Works in multiple IT solutions to gather complete clinical and financial information for comprehensive written appeals. Other duties as assigned.

Knowledge, Skills, And Abilities

Extensive understanding of CPT, HCPCS, ICD, UB-04 Revenue Codes, modifiers, billing, regulations and guidelines for government and commercial payers [Required]
Understanding of charge capture, revenue integrity concepts, and defense of appropriately assigned charges on appeal [Required]
Ability to defend the clinical validation of assigned diagnoses [Required]
Experience with utilization review and understanding of assignment of Inpatient vs. Observation according to appropriate application of MCG and InterQual [Required]
Ability to quickly navigate the electronic medical record, understand services performed, and correlate those services to charges on the bill. [Required]
Strong critical thinking and problem-solving skills with ability to multi-task or reprioritize quickly in a high productivity, fast paced environment [Required]
Ability and willingness to continuously learn new concepts and skills required to navigate ever-changing reimbursement/denials landscape [Required]
Self-starter with the ability to work under limited day-to-day oversight [Required]
Strong written communication / grammatical skills to quickly craft appeal letters that are each individualized according to patient’s severity of illness, intensity of service, denial type, and resource against which necessitated denial [Required]
Proficiency in Microsoft Suite applications, specifically Word, Excel, and Outlook [Required]
Ability to constantly utilize Microsoft Teams to stay in communication with key members, join meetings, and utilize video to maintain presence in the meeting. [Required]
Technical proficiency to independently set up computer system including monitors, docking station, keyboard, and ability to maintain reliable internet service along with backup internet plan for outages, and troubleshoot / resolve problems [Required]
Comfort with interpreting payer contractual language [Preferred]

Education

Bachelor's [Required]
Master's [Preferred]

Field of Study

in field such as nursing, management, business (if Bachelor’s degree in non-nursing field, must have at least an Associate’s Degree in Nursing)
Advanced degree in any field of study

Work Experience

1+ icu and/or medical surgical unit or at least one (1) year of demonstrated proficiency in appeals writing for all hospital services [Required]
2+ utilization review/utilization management experience of utilizing interqual and/or mcg or appeal experience of at least 2 years utilizing interqual and/or mcg [Required]
3+ as registered nurse (rn) in an acute clinical setting [Required]
Denial management, utilization review, case management, clinical documentation improvement, revenue integrity, or related field [Preferred]

Licenses and Certifications

Registered Nurse (RN) [Required]
Certified Case Manager (CCM) [Preferred]
Certified Clinical Documentation Specialist (CCDS) [Preferred]
Accredited Case Manager (ACM) [Preferred]

Physical Requirements

(Please click the link below to view work requirements)

Physical Requirements - https://tinyurl.com/23km2677

Pay Range

$71,385.60 - $132,787.20

Background Screening Requirement (Florida Law)

Certain positions are subject to Florida Level 2 background screening, including fingerprinting, as required by state law.

Applicants may review general information about Florida’s background screening requirements at the Florida Care Provider Background Screening Clearinghouse:

https://info.flclearinghouse.com/

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.

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