Clinical Denial Specialist - Case Mgmt

Location: Beverly, MA
Job ID: 166184-1A
Date Posted: Mar 26, 2021
Category: Nursing

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Job Description

Welcome To

Welcome to Beverly Hospital, part of Beth Israel Lahey Health. Beverly Hospital is a full service, community hospital providing leading-edge, patient-centered care to North Shore and Cape Ann residents. The hospital provides a full-range of state-of-the-art care and services including primary care, cardiovascular care, surgery, orthopedics, emergency care, maternity, pediatrics, as well as many other specialties. Beverly Hospital is nationally recognized for patient safety as it is one of only 42 hospitals in the United States to be awarded an “A” grade from The Leapfrog Group – the nation’s leading nonprofit watchdog on hospital quality and safety.

 

Beverly Hospital 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 Community, Respect, Excellence, Accountability, Teamwork and Empathy.

 

About the Job

The Clinical Denials Specialist assesses, plans, coordinates, and evaluates initial and ongoing governmental and commercial denials. The Denials Specialist 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 to develop a stratagy for retroactive and concurrent denials.

The Denials Case Manager directly reports to the Manager of Case Management.

Scheduled Hours

24 hours per week, day shift.

About Us

Beth Israel Lahey Health is an integrated system providing patients with better care wherever they are. Care informed by world-class research and education. We are doctors and nurses, technicians and social workers, innovators and educators, and so many others. All with a shared vision for what healthcare can and should be. We are committed to attracting, developing and retaining top talent. We strive to create a diverse and inclusive workplace that reflects the communities in which we work and serve. With a team approach to care, we encourage learning and growth at all levels and offer competitive salaries and benefits.

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

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