RN Clinical Appeals

Ensemble Health Partners; United States; Remote; USD 56,000 - 109,000; Full time

Job summary

Join a forward-thinking company that prioritizes customer obsession and innovation in healthcare. This role is essential in managing clinical appeals for denied claims, ensuring that healthcare providers receive the support they need to deliver exceptional care. With a commitment to professional development, you will have opportunities for certifications and tuition reimbursement. Enjoy a culture that values collaboration and growth, while contributing to a mission that keeps communities healthy. If you are passionate about making a difference in healthcare, this position offers a rewarding career path.

Benefits

Bonus Incentives

Paid Certifications

Tuition Reimbursement

Comprehensive Benefits Package

Work-Life Flexibility

Qualifications

• Current unrestricted nursing license required.
• CRCR certification needed within 9 months of hire.

Responsibilities

• Analyze and prepare appeals for denied claims.
• Act as liaison between healthcare providers and insurance plans.
• Collaborate with various departments to communicate denial trends.

Skills

Nursing

Clinical Appeals

Claims Analysis

Medical Records Review

Communication Skills

Education

Associates Degree in Nursing

Bachelor's Degree in Nursing

Job description

Thank you for considering a career at Ensemble Health Partners!

Ensemble Health Partners is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country.

Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference!

O.N.E Purpose:

Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.

Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.

Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results.

The Opportunity:

CAREER OPPORTUNITY OFFERING:

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• This position pays between $56,800.00 – $108,900.00 based on experience

The RN Clinical Appeals performs all appeals for clinically related claim denials across Ensemble Health Partners, or in a role that primarily assists with analyzing and reviewing records to prevent future denials, provide clinical records to payers, and prepare for provider-to-provider (P2P) reviews. Job duties include, but are not limited to, contacting insurance plans to determine reasons claims were denied, analyzing the claims and determining if appeal is necessary, preparing the appeal materials which may include correcting and resubmitting claims, gathering additional information, including reviews of medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner. In addition, the Specialist will work closely with other departments, such as Case Management, HIM, Physician Advisory, Clinical Denials, Denial Prevention, Accounts Receivable, Bedded Inpatient Authorization and Virtual Utilization review, to ensure denial trends and outcomes are communicated in a timely manner. The Specialist will perform these duties while meeting the mission of Ensemble Health Partners, as well as meeting the regulatory compliance requirements.

Essential Job Functions:

• Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.
• Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.
• Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results.
• Contacting insurance plans to determine reasons claims were denied, analyzing the claims and determining if appeal is necessary, preparing the appeal materials which may include correcting and resubmitting claims, gathering additional information, including reviews of medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner.In addition, work closely with the Case Management Department and HIM Department to ensure denial trends and outcomes are communicated in a timely manner.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Associates may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation.

Employment Qualifications:

• Current unrestricted license to practice nursing (LPN, RN)
• CRCR or other approved professional certification required with 9 months of date of hire

Job Experience:

• 1 to 3 Years

Desired Education Level:

• Associates Degree or Equivalent Experience

Preferred Area of Study:

• Nursing

Other Preferred Knowledge, Skills and Abilities:

• 4 year/ Bachelors Degree
• Preferred Minimum Education - Specialty/Major: Registered Nurse (RN) or relevant discipline
• Minimum Years and Type of Experience: 2 years of denials, utilization review, or case management experience strongly preferred

Other Knowledge, Skills and Abilities Required:

• Experience in hospital operations, chart audit/review, and provider relations.

Join an award-winning company

Five-time winner of “Best in KLAS” 2020-2022, 2024-2025

Black Book Research's Top Revenue Cycle Management Outsourcing Solution 2021-2024

22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in Revenue Cycle 2019-2024

Leader in Everest Group's RCM Operations PEAK Matrix Assessment 2024

Clarivate Healthcare Business Insights (HBI) Revenue Cycle Awards for strong performance 2020, 2022-2023

Fortune Media Best Workplaces in Healthcare 2024

Monster Top Workplace for Remote Work 2024

Great Place to Work certified 2023-2024

Work-Life Flexibility

Leadership

Purpose + Values

Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include:

• Associate Benefits – We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.

Our Culture – Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.

Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.

Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.

Ensemble Health Partners is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws. Ensemble Health Partners also prohibits harassment of applicants or employees based on any of these protected categories.

Ensemble Health Partners provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact [e-mail] .

This posting addresses state specific requirements to provide pay transparency. Compensation decisions consider many job-related factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position. A candidate entry rate of pay does not typically fall at the minimum or maximum of the role’s range.

Ensemble Health Partners is the leading revenue cycle management company for hospitals. We build relationships & find the best solutions to your challenges.