Job Details

Job Purpose

The Clinician, Denials Prevention, uses their clinical and administrative skills to analyze denials and appeal outcomes; share opportunities with clients to reduce first pass denials by ensuring proper patient status, authorizations, clinical documentation opportunities, staff education, and collaboration with other departments.

Duties & Responsibilities

• Maintain the integrity of information in each appeal produced
• Review a high volume of written appeals to ensure information is medically accurate
• Research payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment
• Make recommendations for workflow revisions to improve efficiency and reduce denials
• Present case studies and recommendations to clients and impacted stakeholders
• Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate
• Identify opportunities for process improvement and actively participate in process improvement initiatives, internally and externally
• Other duties as assigned
• Use, protect and disclose patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

• Understand and comply with Information Security and HIPAA policies and procedures at all times
• Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties

Qualifications

• Bachelor's degree in a health-related field; 2 years of experience may be considered in lieu of a degree in addition to the required experience. LPN or RN preferred.
• Two years of recent experience in hospital case management, hospital prior authorization, or utilization management
• Experienced in medical chart review
• Claim-related appeal writing experience preferred
• Experience with medical and insurance terminology, CPT, ICD coding structures, and billing forms
• Experience with MCG and/or InterQual guidelines preferred
• Proficiency in Microsoft Office Suite
• Strong interpersonal skills, ability to communicate well at all levels of the organization
• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
• High level of integrity and dependability with a strong sense of urgency and results oriented
• Excellent written and verbal communication skills required
• Gracious and welcoming personality for customer service interaction

Working Conditions

• Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes.
• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.