Clinical Denials Specialist

Job SummaryThe Clinical Denial Speciialist (CDS) serves as an integral member of the Advanced Access Center (AAC) who will be responsible for proactive denial prevention as well as reactive denial management. The CDS will approach denial prevention through encounter audits to identify discrepancies in the code that was authorized, and the final code put on the claim to avoid a denial.The incumbent will act as the liaison between the AAC and provider's offices to ensure the correct codes for the service are authorized and any mid-procedure surgical coding changes are reauthorized within the timely filing period according to the payer. The Clinical Denial Specialist is responsible for planning and executing denial mitigation and recovery programs for all Tower Health Hospitals.

The Clinical Denial Specialist will be directly responsible for securing pre-service approvals, reviewing pre/post service denials, medical necessity review and coordinating peer to peer reviews as appropriate. In collaboration with hospital patient access and revenue cycle, the incumbent will conduct comprehensive root cause denial analysis to identify trends to prevent future denials. The CDS will perform medical review to ensure complete and accurate physician/staff documentation is present to support medical necessity.The CDS will research regulatory policies to support clinical coding as well as education provided to providers, hospital staff and patient/family as necessary to bring the account into resolution.

The position reviews third party payer reimbursement denials based on the following: documentation, billing accuracy, medical necessity, coding, modifier and related issues. Using data from these reviews to identify and rectify billing and documentation errors.Additionally, this position will actively manage, maintain and communicate denial / appeal activity to appropriate stakeholders and report suspected or emerging trends related to payer denials to Revenue Cycle management. This position anticipates and responds to a wide variety of issues/concerns.

The position works independently to plan, schedule and organize activities that directly impacts hospital reimbursement. This role is key to securing reimbursement and minimizing organizational write offs.This Full Time Role requires either a RN or LPN#READQualificationsEducation Requirements Graduate of an accredited school of NursingExperience Relevant ExperienceCertification and Licensure Registration as a professional nurse in the State of PA, RN or LPNRequired Skills Analytical Skills Collaborative Skills Computer Skills to include use and navigation Customer Service Skills Detail Oriented Excellent Communications Skills Excellent Interpersonal Skills Excellent Teamwork Skills Good Reasoning Skills Leadership Skills Listening Skills Medical Terminology Microsoft Access Microsoft Excel Microsoft Outlook Microsoft Word Multitasking Organizational Skills Prepare & Give Presentations Problem Solving Skills Project Management Skills Service Orientation Strategic Planning Skills Strategic Thinking Strong Team Player