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Outpatient Denial/Appeals Specialist- RN

Carle Health • Full-time • Urbana, IL, US • 3w ago

Position Summary

Serves as an expert resource in outpatient clinical documentation review to establish and manage clinical and prior authorization denial appeals for the Carle enterprise. Represents Carle in clinical meetings and writing appeals on outpatient accounts where medical necessity, level of care or prior authorization is questioned. Performs outpatient post payment reviews where medical necessity is being challenged. Responsible for enterprise wide outpatient clinical review and appeals on Medicare and Medicaid RAC, PERM, CERTs, etc. audits. Assists account representatives with the interpretation of specific payer medical policies. Serves as a liaison with the clinical leadership as well as the payer provider representatives. Creates training materials and process flows. Participates in projects. Involved in system testing and development. Builds and analyzes management summary reports.

Qualifications

EDUCATIONAL REQUIREMENTS

Bachelor's Degree in Nursing

Certification & Licensure Requirements

Registered Professional Nurse (RN) License Illinois upon hire.

Experience Requirements

Three years of experience in health care with focus in reimbursement and/or case management. Proficient in Microsoft Office applications such as Word, Excel, Outlook, Access, Visio, Receivables Management systems and Epic reporting tools (Account Query, Cubes, etc.).

Skills And Knowledge

Requires excellent verbal and written communication, negotiation and listening skills. Must be a self-starter who is adept at problem solving and possesses the skills necessary to plan, organize and achieve goals. Performs highly complex and varied tasks requiring independent decision making skills. Ability to multi task and adhere to work plans and time lines. Excellent attention to detail and follow-through. Is innately inquisitive and serves as a role model to others throughout the organization.

Essential Functions

Must be able to perform essential clinical reviews in order to establish medical necessity for outpatient services provided and billed and author effective clinical denial and prior authorization appeal letters.
Stay abreast of any payer changes as well as government regulatory changes.
Facilitates maximization of revenue by ensuring correct coding initiative and payer specific guidelines are applied appropriately and claims are appealed as necessary.
Works with coding and the physicians to improve documentation to support medical necessity and/or to clarify documentation in the medical record.
Responds to telephone requests from insurance companies when medical necessity is questioned.
Monitors dashboard for assigned payers. Analyzes AR and optimizes collection of accounts receivable.
Participates in system testing and development related to system upgrades and process improvements.
Assists in evaluation of billing opportunities related to new technology and/or services.
Builds and analyzes management reports to identify patterns and trends and recommends opportunities for improvement.
Participates in projects.Assists with developing policies and procedures, training materials and process flow to ensure best practice.
Responsible for the clinical review and appeals for the Carle enterprise on all outpatient Medicare and Medicaid RAC, PERM, CERT, etc. audits.
Participates in team meetings and provides direction to team members.
Serves as an internal resource for revenue cycle management on clinical matters.Reviews outpatient post payment denials when medical necessity is being questioned.
Represents Carle in external venues such as court appearances, fair hearings, meeting with employers, attorneys, insurance companies, community events etc.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.

Effective September 20, 2021, the COVID 19 vaccine is required for all new Carle Health team members. Requests for medical or religious exemption will be permitted.

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