Community Health Systems Denial Specialist II- Clinical in Fort Smith, Arkansas

Description:

ESSENTIAL JOB FUNCTIONS:

· Working knowledge of all facets of insurance claim filing, requirements, and regulations

· Review and perform all retrospective inpatient authorizations of days of stays

· Reviews, investigates and appeals all clinical level denials such as not medically necessary surgeries, inpatient stays or levels of care

· Communicates results of audit/review results timely

· Audit Medical Records to retrieve clinical information requested from payers, governmental agencies, etc.

· Draft (in conjunction with a physician reviewer when indicated) appeal letters

· Review and process all correspondence including approvals and denials/adjustments, demand letters and results from various levels of appeals.

· Actively participate in trend analysis and denial prevention program development, including needing training and education internally and externally

· Audit Medical Records to retrieve clinical information requested from payers, governmental agencies, etc.

· Manages the operational aspect of other types of audits when requested

· Maintain knowledge of SSC policies and procedures as it relates to department job functions

· Ensures the appeal process flow for clinical staff and physicians meet appeal deadlines

· Working with team to monitor, track, trend and coordinate denial resolution with facilities

o Attend Team Meetings for internal process improvement and education as needed

· Establishes and maintains insurance payor, employer, vendor and provider representative relationships.

· Coordinates with other SSC Coordinators in respective areas to drive process change and enhancement including payer issues related to appeals process

· Identifies trends with denials and provides communication and education to all necessary parties

· Communicates with all parties in a professional manner to alert specific problem issues

· Ensure confidentiality of all patient accounts by following HIPAA guidelines

· Adheres to compliance of CMS and other payer guidelines

· Attend in-services, education sessions and department meetings as scheduled

· Displays an overall teamwork design, relationship building and coordination of activity.

· Practices the Standards of Service for the Shared Services Center.

· Performs other duties as assigned by leadership.

Qualifications

EDUCATION, SKILLS & EXPERIENCE:

· Licensed as an RN, LPN or LVN (must possess and maintain a current nursing license)

· Bachelor s degree desirable, but equivalent job experience will be considered

· At least 3 years of experience as a Case or Resource Manager is desired

· At least 3 years of experience as a hospital-based nurse is desired

· At least 1 year experience with medical necessity appeals at all levels is preferred

· Working knowledge of the revenue cycle

· Working knowledge of medical terminology and/or insurance claim filing experience

· Detail oriented, analytical and ability to problem solve

· Excellent written and oral communication skills

· Working knowledge of Microsoft Word and Excel or equivalent

· This is a Safety Sensitive position.

Job: Credit & Collection

Organization: Shared Services Center - Fort Smith

Location: AR-Fort Smith

Requisition ID: 1834540