Clinical Denials Specialist

Firstsource; Louisville (KY); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Medical

Vision

Dental

401K

Paid Time Off

Job summary

Firstsource is seeking a Clinical Denial Specialist in Louisville to manage claim denials across referrals, authorizations, and medical necessity. You will review claims, draft timely appeals, and track outcomes and trends to inform denial management strategies.

Responsibilities include researching payer denials, writing professional appeals, preparing management reports, and ensuring adherence to HIPAA and payer regulations. Strong EHR experience and clinical background preferred.

Qualifications

• Associates Degree in a business or healthcare related field.
• Registered Nurse (RN) Certification with experience in care management, utilization review, prior authorization and appeals.
• Electronic Health Record Experience with various platforms (Epic, Cerner, Meditech).
• Knowledge of all insurance payers preferred.
• Proficient PC knowledge and the ability to type 30-40 wpm.
• Professional written and verbal communication skills.
• Capacity to prioritize multiple tasks in a busy work environment.
• Organization and time management skills.
• Capability to present oneself in a courteous and professional manner at all times.
• Ability to stay on task with little or no supervision.

Responsibilities

• Research assigned payer denials (referral, authorization, notification, medical necessity and non-covered services).
• Write/submit professional appeal letters in accordance with client and payer policies.
• Prepares reports for management review and identifies trends.
• Reviews and understands utilization review and coverage guidelines for multiple payers.
• Identify process improvement opportunities.
• Monitor denial and appeal outcomes and report findings to management.
• Ensure all denial management activities comply with federal, state and payer regulations, including HIPAA requirements.

Skills

Communication

Multitasking

Time management

Organization

Independent work

Research skills

Education

Associates Degree in business/healthcare

RN Certification

Tools

Epic EHR

Cerner EHR

Meditech EHR

Payer knowledge

Job description

Role: Clinical Denial Specialist
Schedule:M - F 8 AM - 4:30 PM EST

GENERAL SUMMARY:

• The goal of theClinical Denial Specialist is to successfullymanage claim denials related to referral, authorizations, notifications, non-coverage, medical necessity, and other clinically related denials, as assigned. The specialist will review claims and make recommendations for claim resubmission, retro authorization, written appeal or if no action is needed.
• The Clinical Denial Specialist will write / submit professionally written appeals including arguments based on the clinical documentation, payer medical policies and contract language. The appeals will be submitted timely and tracked for outcome and trends.

Foundation Knowledge, Skills, and/or Abilities Required:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Essential Duties and Responsibilities:

• Research assigned payer denials (referral, authorization, notification, medical necessity and non-covered services)
• Independently write / submit professional appeal letters in accordance with client and payer policies
• Prepares reports for management review and identifies trends.
• Reviews and understands utilization review and coverage guidelines for multiple payers
• Identify process improvement opportunities
• Monitor denial and appeal outcomes and trends, and report findings to management.
• Ensure all denial management activities comply with federal, state and payer regulations, including HIPAA rerquirements.

Additional Duties and Responsibilities:

• Meet specified goals and objectives as assigned by management on a regular basis.
• Maintain confidentiality of account information at all times.
• Maintain awareness of and actively participate in the Corporate Compliance Program.
• Assist with other projects as assigned by management
• Maintain good working relationships with state and Federal agencies.
• Resolve accounts in a timely manner.
• Maintain a neat and orderlywork station

Educational/Vocational/Previous Experience Recommendations:

• Associates Degreein a business or healthcare related field.
• Registered Nurse (RN) Certification with experience in care management, utilization review,prior authorizationand appeals.
• Electronic Health Record Experience with various platforms (Epic, Cerner, Meditech)
• Knowledge of all insurance payers preferred.
• Proficient PC knowledge and the ability to type 30-40 wpm.
• Professional written and verbal communication skills.
• Capacity to prioritize multiple tasks in a busy work environment.
• Organization and time management skills.
• Capability to present oneself in a courteous and professional manner at all times.
• Ability to stay on task with little or no supervision.

Working Conditions:

• Must be able to sit for extended periods of time.

Benefits including but not limited to:

• Medical
• Vision
• Dental
• 401K
• Paid Time Off.

We are an Equal Opportunity Employer. All qualified applicants are considered for employment without regard to race, color, age, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by federal, state or local law.

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