Clinical Denial Specialist - Case Management

Location: Beverly, MA
Job ID: 152354-1A
Date Posted: Jun 3, 2019

Job Description

Welcome To

 

Beverly Hospital  is part of a vibrant and growing health care system, recognized as a trailblazer in medicine and a standard bearer in patient experience. It includes an award-winning academic medical center, a superb constellation of community hospitals, home care services, rehabilitation facilities and more.

We are committed to attracting, developing and retaining top talent in a market long recognized and revered as a global leader in health. With a team approach to care, we encourage learning and growth at all levels, and we offer competitive salaries and benefits. We adhere to the principles of a just and fair work environment for all colleagues, where respect is foundational and performance is rewarded.

About the Job

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. 

Position Summary:

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.

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.

Scheduled Hours

18 hours per week, varied hour/ shifts with week-end and holiday rotation as needed for department needs and deadlines .

 

This is not a remote position

About Us

The Lahey Model of Care—right care, right time, right place—is exactly what patients, providers and payers need and deserve. Identifying and delivering on this convergence of interests has positioned Lahey Health for further growth. Our model ensures care is highly coordinated and locally delivered, with lower costs and exceptional quality.

Lahey Health is a robust, regional system including a teaching hospital, community hospitals, primary care providers, specialists, behavioral and home health services, skilled nursing and rehabilitation facilities, and senior care resources throughout northeastern Massachusetts and southern New Hampshire. The system has a global presence with programs in Canada, Jordan and Bermuda.

Equal Opportunity Employer/Minorities/Females/Disabled/Veterans.

Qualifications

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. Recent acute care experience.   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