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Clinical Denial Specialist, Case Management

Job ID 149590 Date posted 08/19/2018

Beverly Hospital, A member of Lahey Health, promotes the culture and philosophy which enables employees to give and receive the best of care. You can become a part of the team that achieves this success through our CREATE values of Compassion, Respect, Excellence, Accountability, Teamwork, and Empathy.

The Clinical Denials Specialist assesses, plans, coordinates, and evaluates initial and ongoing governmental and commercial denials. He/She obtains information on all denials occurring as related to observation and inpatient stays. The denials specialist researches and responds to denials in a timely fashion. He/she identifies trends and responds to the trends by recommending changes in practice and or documentation of the providers to promote a reduction in the denials trends. The denials specialist collects and trends the data as it relates to denials and reports that data to the Manager of Case Management for review.

Position Summary:

The Clinical Denials Specialist utilizes nursing knowledge, information science, and interpersonal skills to support and represent the optimal denials prevention processes identified with all medical, clinical and ancillary departments. The denials specialist attends denials meetings. The denials specialist coordinates with the Physician Advisor retroactive and concurrent denials. This position reports directly to the Manager of Case Management.

Responsibilities

Concurrently reviews all medical and surgical denials and provides a recommendation for responding or not responding to the denials.

Appeal payment of services denied by Medicare, Medicaid, and Commercial payers by writing and presenting appeals to Insurance Reviewers, Hearing Officers, and Administrative Law Judge
Works with Professional Providers and Hospital Departments to, bill under correct admission category and educate on required documentation for the prevention of denials
Understands the payer contracts and responds to denials within the constraints of those contracts. Uses information on medical necessity and appropriateness of admission stay in accordance with ISDA screening and utilization of the Medicare inpatient only list in response to the denials.
Works with patient financial services and concurrent case managers to understand the requirements of all payers who have contracts with NHC and develop a process to prevent denials from occurring.
Provide support and education to the case managers for the concurrent denial process to prevent a denial from happening.
Trends the data and works with contracting and patient financial services to address some of the denial; issues through the contracting process.
Identifies education opportunities for the clinicians and unit case managers to proactively and concurrently address denials.
Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.
Collaborates with the other case managers and helps to respond to all pre-certification denials while identifying the issues and providing a proactive appropriate to pre-certification denials management.
Serves as a liaison and mentor to the multidisciplinary team for questions regarding system-wide processes for the denials management.
Identifies opportunities for improving processes for collecting, analyzing and communicating performance improvement indicators.
Performs other duties and responsibilities as assigned and prioritized by the Manager of Case Management.

Qualifications

Graduate of an accredited School of Nursing with current RN licensure from Massachusetts. Bachelor?s degree in Nursing is required. A minimum of 5 years current experience in denials management or direct work for Recovery Audit Contractors is required, and experience with DRG clinical validation appeals preferred. Extensive knowledge of national standards for acute inpatient medical necessity criteria and Federal and State National and Local Coverage Determinations is required. Prior experience with Third Party Payor denial management including appeals to the Administrative Law Judge on the governmental and commercial levels is also required. Excellent oral and written communication skills

Ability and willingness to exhibit behaviors consistent with standards for performance improvement and organizational values.
Demonstrated computer skills, including familiarity with MS Word and Excel, email systems, internet, intranet, and facility-based documentation systems.
Ability to analyze and draw conclusions from performance improvement data

Scheduled Hours

12 hours per week, variable day each week depending on the needs of the department.