Revenue Cycle Clinical Denials Specialist

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Summary:

The Revenue Cycle Clinical Denials Specialist will perform advanced level work related to clinical denials management and root cause analysis. Responsibilities include managing claim denials related to authorization, referral, late notifications, level of care, medical necessity, experimental and investigational, and all other denials as assigned. The Revenue Cycle Clinical Denials Specialist conducts comprehensive review of the claim denials, account and/or charge reconciliation, and all clinical documentation to determine the root cause and appropriate resolution.

The Clinical Denials Specialist will write and submit professionally written appeals to encompass compelling arguments based on clinical documentation, payors' clinical and medical policies, including CCHCS contract and reimbursement language, as appropriate. Appeals and/or reconsiderations should follow payor guidelines and regulations to ensure timely submission. The position will also track denial trends through outcome, identify recurring issues, and provide process improvement opportunities to minimize future denials through education. The Clinical Denials Specialist will also share responsibility for audit-related and compliance; and other administrative duties as required.

The position will manage, maintain and communicate denial and appeal activity to the appropriate stakeholders, and report emerging trends to Revenue Cycle leadership. The Revenue Cycle Clinical Denials Specialist anticipates and responds to a variety of issues and concerns; including organizing activities directly affecting hospital reimbursement and assists in creating and maintaining documentation of key processes.

The individual works independently to plan and organize activities that directly influences hospital reimbursement and assists in creating and maintaining documentation of key processes. This role is essential to securing reimbursement and minimizing organizational adjustments under the direction of Revenue Integrity leadership.

Education:

• High School diploma or equivalent required

• Associate or Bachelor's Degree in business or healthcare related field, preferred

Experience:

• 3 years' recent experience in hospital revenue cycle denials management, medical billing and/or insurance collections.

• 2 years' experience in professional business writing, hospital case management and/or hospital clinical operations.

• 1 year experience in claim-related appeal writing.

• Proficient use of Excel and data analysis techniques to collect, analyze, interpret data.

Knowledge, Skills & Abilities:

• Ability to construct an effective argument related to clinical denials for hospital services

• Knowledge of health plan operations, reimbursement methodologies, payor contracts and clinical and medical policies

• Working knowledge of state, federal and compliance regulations as they pertain to coding and billing processes and procedures

• Strong understanding of medical billing principles, insurance coding (CPT, HCPCS, ICD-10 and billing forms), medical and insurance terminology, and payor polices, and appeals processes

• Excellent written and oral communication skills to manage complex appeals, reconsiderations and denials

• Ability to ensure a high-level of customer satisfaction for internal and external stakeholders

• Basic math skills and knowledge of healthcare related financial and/or accounting practices

• Ability to maintain strong relationships with various clinical and non-clinical team members that positively affect financial outcomes

• Analytical skills, attention to detail, excellent communication, and strong problem-solving abilities

• Working knowledge of medical decision-making criteria tools (InterQual, Milliman Care Guidelines)

• Ability to deal effectively with constant changes and be a change agent.

• Possesses the ability to work in a constantly changing environment, good judgement skills, and capable of making decisions with attention to detail

• Prior experience with Epic Systems Revenue Cycle Solutions (HB Resolute) required

Licensure, Registration, and/or Certification:

• Licensed Vocational Nurse (LVN), Certified Professional Coder (CPC), (CIC), (COC), or Certified Professional Biller (CPB) preferred

About Us:

Cook Children's Medical Center is the cornerstone of Cook Children's, and offers advanced technologies, research and treatments, surgery, rehabilitation and ancillary services all designed to meet children's needs.

Cook Children's is an EOE/AA, Minority/Female/Disability/Veteran employer.