Clinical Denials & Appeals Nurse Specialist

Job Description

Strong communicator with proven ability to collaborate across interdisciplinary teams while maintaining compliance with healthcare regulations.

Job Responsibilities:

Denials and Appeals Management:

• Work denials and appeals timely, evaluating the denial reason including information from the payor and payor policies, reviewing the clinical documentation, assessing options and completing next steps
• Submit retro-authorizations in accordance with payor requirements in response to authorization denials
• Conducts medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals.
• Write and submit written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. Appeals are submitted timely and tracked through final outcome.
• Document all actions taken and follow-up timely as needed related to resolving denials and appeals with third-party payers in a timely manner
• Tracks the status and progress of denials and appeals
• Completes relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
• Executes internal and external correspondence accurately, clearly, concisely, and professionally while following organizational regulations
• Effectively handles all communications, including telephone, electronic, and paper correspondence from payers and departments within the business office

Tracking, Reporting, and Trends:

• Maintains data on the types of claims denied and root causes of denials
• Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution
• Collaborate with management to recommend process changes to address root cause of denials and overall improvement to reduce A/R
• Prepares, maintains, assists with, and submits reports as required

Compliance and Continuous Improvement:

• Collaborate with team members to continually improve services, and engage in process and quality improvement activities
• Identify system improvement opportunities and contribute to the testing of system modifications
• Conducts relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms
• Complies with state and federal regulations, accreditation/compliance requirements, and Huron's policies, including those regarding fraud and abuse, confidentiality, and HIPAA
• Maintains a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, in order to identify and report billing compliances issues and payer discrepancies
• Participates in ongoing professional development to enhance job knowledge and performance
• Reports all identified compliance risks to appropriate leadership

Qualifications:

Required Qualifications - (Non-Negotiables)

Clinical Appeals Experience:

• At least 1 year of clinical appeal writing experience.
• 3–5 years acute care (Med/Surg preferred); 2–3 years ICU.
• Education: BS in Nursing.
• Licensure: Active PHRN or USRN.
• Knowledge: InterQual/MCG guidelines, U.S. insurance regulations, hospital EMRs (Epic, Cerner, Meditech).
• Skills: Strong English communication (CEFR B2+), customer service.

Preferred:

• Education: Masters in business/healthcare or related.
• Certification: Case management/appeals/denials (ACMA).
• Software: Denials/appeals tracking tools, Microsoft Office suite