Clinical Denials Nurse Specialist

The Clinical Denials Nurse Specialist performs advanced-level work related to clinical denial management. The individual is responsible for managing medical denials by conducting a comprehensive review of clinical documentation. The Clinical Denials Nurse Specialist will write compelling arguments based on the clinical documentation and the medical policies of the payor and submit the appeal in a timely manner. This position applies clinical knowledge to assess and ensure services/items billed are reasonable and necessary, supported by national/local coverage determinations and commercial medical policies, and meet standards of medical care. This position is also responsible for adapting to a wide variety of medical review topics. The Clinical Denial Nurse Specialist will also handle audit-related / compliance responsibilities and other administrative duties as required. 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 Clinical Denials Nurse Specialist works independently to plan, schedule and organize activities that directly impact hospital and physician reimbursement. This role is key to securing reimbursement and minimizing organizational write offs.

Responsibilities

• Maintains an extensive caseload of clinical denials, appeals and audits as assigned.
• Formulates strategy for prioritizing cases and maintains aging within appropriate ranges with minimal direction or intervention from Leadership.
• Collaborates with Coding Denials Specialist and Leadership in high-dollar claim denial review and ensures we are addressing any coding components of said claims.
• Composes and submits a comprehensive appeal letter or retro authorization to the insurance carrier based on clinical evidence within the medical record and evidence-based literature.
• Documents and summarizes clinical or administrative rationale for all appeals in EPIC. Documents communications with medical office staff and/or MD provider as required.
• Performs, summarizes and shares root cause with stakeholders for the purpose of executing measurable process improvement
• Acts as a liaison among all Department Managers, Staff, Physicians, and Administration with respect to clinical denials issues. Interfaces with other departments to satisfactorily resolve issues related to appeals and initial denials.
• Assesses clinical data from medical records and utilizes screening criteria (MCG and/or InterQual) to determine appropriate patient status.
• Assures the medical record has the proper physician order and/or clinical documentation.
• Reviews account history for prior authorization/referral submissions or pre-service denials.
• Communicates with Pre-Cert team and/or medical office personnel to obtain pertinent information.
• Maintains a thorough understanding of operations and business unit processes/workflows including, but not limited to authorizations and referral requirements, and in/out-of-network insurances.
• Maintains payer portal access and utilizes said portal to assist in reviewing commercial medical policies or LCD and NCD (local and national coverage determination) rules. Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes.
• Maintains working knowledge of applicable insurance carriers’ timely filing deadlines, claims submission processes, and appeal processes and escalates timely filing requests to Leadership.
• Follows account to resolution to include appropriate financial adjustment.
• Provides feedback to Physicians, Nurses, Operational Leaders, and any others regarding clinical denials.
• Compiles training material and educational sessions associated with clinical denial-related topics and presents such educational materials. Assists with and/or provides suggestions for continuing education topics.
• Monitors for clinical denial trends, works collaboratively with the revenue cycle teams to reduce revenue loss.
• Participates in CMS and other audits and related activities as required.
• Organization Expectations, as applicable:
• Fulfills all organizational requirements.
• Completes all required learning relevant to the role.
• Complies with and maintains knowledge of all relevant laws, regulations, policies, procedures and standards.
• Fosters a culture of improvement, efficiency and innovative thinking.
• Recommends process efficiencies, strategies for improvement and/or solutions to align with business strategies.
• Participate in process improvement meetings and/or discussions, recommending process efficiencies and/or strategies for denial prevention and revenue improvement.
• Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Adheres to HIPAA compliance rules and regulations.
• Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.
• Educates and mentors new employees through the on-boarding process.
• Adheres to productivity and quality standards.
• Performs other duties as assigned.

Required Qualifications

• 2 years recent experience in a clinical area or case management / pre-certification
• Licensed Registered Nurse

Preferred Qualifications

• Graduate of School of Nursing
• Epic experience in either Resolute Hospital or Professional Billing
• 3 years of experience in a healthcare revenue cycle or clinic operations role with progressive leadership responsibilities
• Experience in managing and appealing denials 
• Previous experience with appealing J Code denials
• In-depth familiarity with third party billing requirements and regulations, billing documentation requirements
• Understanding of CPT and HCPCS coding guidelines
• Expertise with InterQual and Milliman disease management ideologies
• Expertise in reading and interpreting commercial payer medical policies
• Previous work at a commercial payer
• Previous training experience
• MN Registered Nurse (RN) License Registration as a professional nurse in the State of Minnesot

$80,100.80- $113,068.80 Annual