Clinical Denials Management Specialist

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

• Extensive understanding of CPT, HCPCS, ICD, UB-04 Revenue Codes, modifiers, billing, regulations and guidelines for government and commercial payers [Required]
• Understanding of charge capture, revenue integrity concepts, and defense of appropriately assigned charges on appeal [Required]
• Ability to defend the clinical validation of assigned diagnoses [Required]
• Experience with utilization review and understanding of assignment of Inpatient vs. Observation according to appropriate application of MCG and InterQual [Required]
• Ability to quickly navigate the electronic medical record, understand services performed, and correlate those services to charges on the bill. [Required]
• Strong critical thinking and problem-solving skills with ability to multi-task or reprioritize quickly in a high productivity, fast paced environment [Required]
• Ability and willingness to continuously learn new concepts and skills required to navigate ever-changing reimbursement/denials landscape [Required]
• Self-starter with the ability to work under limited day-to-day oversight [Required]
• Strong written communication / grammatical skills to quickly craft appeal letters that are each individualized according to patient’s severity of illness, intensity of service, denial type, and resource against which necessitated denial [Required]
• Proficiency in Microsoft Suite applications, specifically Word, Excel, and Outlook [Required]
• Ability to constantly utilize Microsoft Teams to stay in communication with key members, join meetings, and utilize video to maintain presence in the meeting. [Required]
• Technical proficiency to independently set up computer system including monitors, docking station, keyboard, and ability to maintain reliable internet service along with backup internet plan for outages, and troubleshoot / resolve problems [Required]
• Comfort with interpreting payer contractual language [Preferred]

• Bachelor's [Required]
• Master's [Preferred]

• in field such as nursing, management, business (if Bachelor’s degree in non-nursing field, must have at least an Associate’s Degree in Nursing)
• Advanced degree in any field of study

• 1+ icu and/or medical surgical unit or at least one (1) year of demonstrated proficiency in appeals writing for all hospital services [Required]
• 2+ utilization review/utilization management experience of utilizing interqual and/or mcg or appeal experience of at least 2 years utilizing interqual and/or mcg [Required]
• 3+ as registered nurse (rn) in an acute clinical setting [Required]
• Denial management, utilization review, case management, clinical documentation improvement, revenue integrity, or related field [Preferred]

• Registered Nurse (RN) [Required]
• Certified Case Manager (CCM) [Preferred]
• Certified Clinical Documentation Specialist (CCDS) [Preferred]
• Accredited Case Manager (ACM) [Preferred]

Certain positions are subject to Florida Level 2 background screening, including fingerprinting, as required by state law.

Applicants may review general information about Florida’s background screening requirements at the Florida Care Provider Background Screening Clearinghouse:
https://info.flclearinghouse.com/

This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.