RN 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.

• Reviews and appeals clinical denials across all service lines system-wide

• Researches account histories, patient encounters, payer portals, and payment records to determine appropriate appeal strategies

• Evaluates denial types including but not limited to charge audit, clinical validation, experimental services, payer policy denials, level of care, NICU, and readmissions

• Executes charge corrections and prepares accounts for rebilling as appropriate

• Collaborates with pre-access, patient financial services, revenue integrity, utilization management, and clinical departments to gather supporting documentation

• Provides reports, education, and training on clinical denial trends and recommended remediation strategies

• Educates stakeholders on proper documentation, payer processes, and policies with a denial prevention focus

• Drafts and submits written and verbal appeals using clear, concise clinical terminology

• Researches root causes, collects supporting documentation, and adjusts accounts based on internal and external findings

• Utilizes multiple IT systems to compile comprehensive clinical and financial information for appeals

• Escalates identified claim issues and trends to appropriate leadership or payer contacts

• Performs other duties as assigned

• Understanding of charge capture, revenue integrity concepts, and defense of appropriately assigned charges on appeal [Required]

• Extensive understanding of CPT, HCPCS, ICD, UB-04 Revenue Codes, modifiers, billing regulations, and guidelines for government and commercial payers [Required]

• Ability to defend the clinical validation of assigned diagnoses [Required]

• Experience with utilization review and understanding of Inpatient vs. Observation assignment using MCG and InterQual [Required]

• Ability to navigate the electronic medical record, understand services performed, and correlate services to charges [Required]

• Strong critical thinking and problem-solving skills with ability to multi-task and reprioritize in a fast-paced environment [Required]

• Ability and willingness to continuously learn new concepts and skills to navigate the ever-changing reimbursement/denials landscape [Required]

• Self-starter with ability to work independently with limited day-to-day oversight [Required]

• Strong written communication and grammatical skills to craft individualized appeal letters based on patient severity, intensity of service, denial type, and applicable regulations [Required]

• Proficiency in Microsoft Suite applications, specifically Word, Excel, and Outlook [Required]

• Ability to utilize Microsoft Teams for communication, meetings, and video presence [Required]

• Technical proficiency to independently set up computer systems, maintain reliable internet service with backup plan, and troubleshoot technical issues [Required]

• Comfort with interpreting payer contractual language [Required]

• Proficiency with Epic EHR system [Preferred]

• Comfort with interpreting payer contractual language [Preferred]

• Bachelor's of Nursing [Required]

• 2+ years of clinical denials or utilization management experience [Required]

• 3+ years’ experience as a Registered Nurse (RN) in an acute clinical setting [Required]

• 1+  year in ICU and/or Medical Surgical Unit [Required]

• 1+ year of demonstrated proficiency in appeals writing for all hospital services. [Required]

• Registered Nurse (RN) [Required]

• Certified Revenue Cycle Rep (CRCR) [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.