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Form of workAdventHealth Corporate
All the benefits and perks you need for you and your family:
Benefits from Day One
Career Development
Whole Person Wellbeing Resources
Mental Health Resources and Support
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 together we are even better.
Shift: Monday-Friday
Job Location: Remote
The role you'll contribute:
This position is responsible for investigating and appealing post-remit denials for all Inpatient and Outpatient clinical services across the system, as well as review and correct charge errors. The ability to effectively communicate with command of the written English language is crucial for basic job functioning. Understanding revenue cycle processes is necessary in order to effectively evaluate the denial root cause and bring about the best opportunity for fair reimbursement. The Clinical Denial Management Specialist will adhere to the AHS Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies, and will develop and maintain cordial working relationships with team members and stakeholders across the system.
The value that you bring to the team:
Reviewing and appealing denials for all clinical services across the AH system
Researching various sources of information to determine appropriateness of appeal vs. other action which includes conducting account history research, navigating patient encounters, reviewing payer website and other resources as applicable, researching charge and payment histories, and any other application necessary to formulate a cohesive and complete clinical appeal or decision regarding other action.
Various types of denial review, appeal, further action which includes but is not limited to: charge audit/charge capture denials, charge correction, clinical validation, services deemed experimental, services denied according to various payer policies, inpatient level of care (MCG or IQ), NICU level of care, readmissions, etc.
Making 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 to be used in the appeals process if necessary.
Provide 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.
Able to defend and appeal denied claims via both written and verbal communication in clear and concise arguments/rationale in clinical terms/language.
Capable of researching underlying root cause, collecting required information or documents, and adjusting the account as necessary based on all related internal and external information sources.
Able to work in multiple IT solutions at one time to ascertain the complete clinical and financial information required to formulate comprehensive written appeals.
Escalates any discrepancies and issues encountered to supervisors in a timely manner.
Keeps up to date on department and organization policies as well as payer and all regulatory and compliance rules and regulations.
The expertise and experiences you'll need to succeed:
Minimum qualifications:
Bachelor's degree 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)
Utilization Review/Utilization Management experience of at least 2 years utilizing InterQual and/or MCG or Appeal experience of at least 2 years utilizing InterQual and/or MCG
Minimum of three (3) years' experience as Registered Nurse (RN) in an acute clinical setting
Clinical experience of at least one (1) year in ICU and/or Medical Surgical Unit or at least one (1) year of demonstrated proficiency in appeals writing for all hospital services
Current and valid RN license
Preferred qualifications:
Comfort with interpreting payer contractual language
Advanced degree in any field of study
Experience in denial management, utilization review, case management, clinical documentation improvement, revenue integrity, or related field
Certification in Case Management (ACMA/CCM)
Certification Clinical Documentation (CDIP)
