CLINICAL APPEALS SPECIALIST

Position Highlights:

Responsible for the administration and coordination of the denials review and appeals management processes that includes denials management, claims recovery, and denial root cause analysis.

The Ideal Candidate:

• Experience in oncology nursing, utilization review, quality management, and/or recent case management and Soarian experience.  

Responsibilities:

• Submit medical necessity appeals electronically and/or mail. Follow up electronically and/or telephonically with payers for claim and appeal status.
• Make a preliminary determination whether denial can be overturned and if initial or secondary appeals should be submitted.
• Research and prepare appeal responses to clinical denials.
• Review of clinical denials including identification of root cause.
• Resolve clinical denials which include researching and reviewing payer guidelines, writing and submitting appeals with supporting documentation if required.
• Identifies coding, billing, or reimbursement errors/discrepancies with the denial or aging claim in order to escalate to the denial recovery supervisor.
• Evaluate denied dollars for both contracting and non-contracting insurance companies; and resolution of reimbursement discrepancies.
• Resolution of denials for medical necessity, utilization review, pre-certification, authorization, and concurrent review to include writing appeals and responsible for conducting and preparing responses.
• Track and trend denials issues for escalation to leadership for process improvement.

Credentials and Qualifications:

• Bachelors Degree plus a minimum of five (5) years healthcare experience and RN required
• (OR) "in lieu of" a Bachelor's degree you must have an Associates degree plus a seven (7) years healthcare experience preferably in Nursing and RN required.

**Accommodation: LPN's currently in the role of Clinical Denial Specialist will be given a specified time frame (2 years) to obtain the RN licensure * "in lieu of" Associate's, a H.S. Diploma with two (2) years of additional related claims/collection experience maybe considered.