[Hiring] Denial Mitigation-Appeal Specialist II RN @Baptist

Role Description

The Denial Mitigation-Appeal Specialist II RN serves in a key role of the BMHCC revenue cycle as demonstrated by the following:

• Performs reviews of clinical information and supporting documentation for acute care inpatient services and other account classes as assigned.
• Determines appeal and other actions such as:
  • Complete level of care downgrades for billing/clinical purposes.
  • Identifying further escalation options.
  • Participating in clinical meetings.
  • Reaching out to payer contacts.
  • Communicating with physician clinics to obtain additional documentation to support appeal.
  • Collaborating with coding/billing for formulation of appeal with corrected claims and denial resolution.
• Reviews the denial received from the payer and completes a thorough analysis of the patient’s clinical record.
• Prepares a clinical timeline and summary of the account to determine next steps.
• Compiles an appeal along with pertinent clinical and financial information to send to healthcare insurance providers in response to post-claim denials.
• May require communication with Physician Advisor for further clinical review.
• Follows the account throughout the entire appeal process and determines if escalation to manager or payer is necessary.
• May be required to defend appeal in a payer hearing or clinical meeting when indicated.
• May have the opportunity to work remotely after 90 days upon meeting productivity requirements and training goals.
• Reports to the manager of the Denial Mitigation Department and performs other duties as assigned.

Qualifications

• RN with 5 years clinical experience in acute healthcare setting.
• 3-5 years insurance provider, auditing, or medical review experience related to denied claims.
• 3-5 years case management experience or other related relevant experience.
• Graduate of an accredited nursing program.

Requirements

• Strong prioritization, organization, and both written and verbal communication skills.
• Extensive knowledge of payer guidelines and BMHCC contracts.
• Strong foundation and knowledge of payer portals.
• Ability to meet quality and productivity standards.
• Reviews, assesses, and evaluates all communications/correspondences to optimize reimbursement.
• Evaluates clinical information and supportive documentation prior to initial appeal action.
• Meticulously reviews extenuating circumstances and other outside variables when responding to technical authorization denials.
• Compiles, analyzes, and distributes pertinent clinical and financial information to healthcare insurance providers.
• Prepares response to denials based on supporting clinical information, applicable payer policies, and regulations.
• Submits retro-authorization requests, reconsiderations, and appeals with careful regard to payer specific timeframes.
• Utilizes and builds knowledge base regarding external appeals, hearings, and escalation options.
• Works closely with physician advisor for assistance with medically complex case appeals.
• Reports denial trends to management to improve performance.
• Completes assigned goals and projects within designated timeframe.

Company Description