Clinical Denials Specialist

Firstsource; United States; On-site; USD 50,000 - 70,000; Full time

Benefits offered by this job

Medical

Vision

Dental

401K

Paid Time Off

Job summary

Firstsource is seeking a dedicated Clinical Denial Specialist to manage claim denials related to referrals and authorizations. Key responsibilities include writing appeal letters and preparing management reports.

The ideal candidate will hold an Associate's Degree and possess RN Certification with experience in care management. Benefits include medical, dental, vision, and 401K.

Qualifications

• Associate's Degree in a relevant field.
• RN Certification with experience in care management and appeals.
• Proficient in electronic health records.

Responsibilities

• Research assigned payer denials.
• Write and submit professional appeal letters.
• Prepare reports for management review.

Skills

Research payer denials

Professional appeal writing

Utilization review knowledge

Process improvement identification

Time management

Education

Associate’s Degree in business or healthcare

Registered Nurse (RN) Certification

Tools

Epic

Cerner

Meditech

Job description

Role: Clinical Denial Specialist

Schedule: M - F 8 AM - 4:30 PM EST

General Summary

The goal of the Clinical Denial Specialist is to successfully manage 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 and 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 and submit professional appeal letters in accordance with client and payer policies
• Prepare reports for management review and identify trends
• Review and understand 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 requirements

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 orderly work station
• Maintain a neat and orderly work station

Educational/Vocational/Previous Experience Recommendations

• Associate’s 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

Working Conditions

• Must be able to sit for extended periods of time

Benefits

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

Equal Opportunity Employer Statement

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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