[Hiring] Clinical Denials & Appeals Specialist @Northwell Career Site

Role Description

This role involves reviewing and responding to Corporate Compliance Audits and serving as a resource for the Health System.

• Reviews denial trends and identifies coding issues and knowledge gaps.
• Serves as liaison between the patient and facility/physician and the third party payer.
• Prepares and defends level of care and medical necessity for assigned case.
• Collaborates with physician advisor, payor representative, and site case managers to facilitate appropriate level of care decisions and billing status.
• Ensures compliance with the Utilization Review standard and regulations.
• Performs concurrent and retrospective utilization management using evidenced-based medical necessity criteria.
• Conducts clinical reviews and formulates appeal letters to support appropriateness of admission and continued length of stay.
• Ensures compliance with current state, federal, and third-party payer regulations.
• Ensures clinical reviews and appeals are up to date and accurately reflect patient’s severity of illness and intensity of services provided.
• Performs related duties as required.

Qualifications

• Graduate from an accredited School of Nursing.
• Bachelor's Degree in Nursing, preferred.
• Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date.
• Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
• Inpatient clinical experience; 4+ years preferred.
• Prior Acute Case Management and/or Utilization Review experience, preferred.
• Must have experience with Milliman Care Guidelines and/or InterQual.

Requirements

• Fully remote role
• Days: Sunday - Thursday
• Hours: 8:00am - 4:00pm

Benefits

• The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.
• When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).