Clinical Denials Coordinator

Description

Summary:
Coordinates and leads all clinical denial processes and clinical audit activities. Supervises and collaborates with teammates involved in the denial process. Reviews all denial requests and leads the team in the strategy to appeal all clinical denials. Provides the clinical expertise to draft the first and second levels of an audit appeal. Works collaboratively with the Physician Advisors and subject matter experts for all audit and appeals work activities. Assists with documentation review to support the clinical documentation specialists

Responsibilities:

1. Provides leadership, clinical expertise and organization to the Denials Management Team within the clinical documentation team.

2. Stays up to date and proactive with all ongoing information, rules and regulations, Medicare and other payor regulations.

3. Reviews all denials and is key point person for assigning team review. i.e. denials to Coding Supervisor.

4. Reviews and documents findings on all medical necessity and status denials.

5. Works closely with Patient Financial Services for issues related to reimbursement, denials, status, etc.

6. Evaluates clinical denials for validity and probability to overturn, proactively gathers required clinical documentation and formulates appropriate appeals. Coordinates the denial team in order to establish appeals plan based on the type of denial.

7. Conducts case studies for those complex denials in order to plan appeal strategies and to educate peers.

8. Conducts pertinent discussions with auditors and follows appropriate appeals process within established timeframes.

9. Reviews and responds weekly to status issue queries from coders, Quality and other entities.

10. Responsible for summary reports of Wayne UNC Health Care denials. Presents denials summary to IM/UR committee bi-monthly and as needed.

11. Reports out at the monthly denial prevention committee on status of at-risk dollars and appeal win rates.

12. Assists in documentation review in the clinical documentation specialist role when needed. Working with Clinicians and Coders to successfully implement documentation review for MS-DRG and AP-DRG payers on assigned Hospital Units.

Other information:
Education
Graduate of an accredited program for professional nursing.
Bachelor's degree in Nursing preferred.

Licensure/Certification
Current North Carolina nursing licensure.

Experience
*Minimum 3-5 years of applied clinical experience as a Registered Nurse required.
*2 years utilization review, care management, or compliance experience preferred.
*Minimum 1 year clinical denials management preferred.

Knowledge, Skills and Abilities
*Solid knowledge and understanding of provider reimbursement methodologies, medical terminology, and hospital and physician billing.
*Knowledge of government and non-government clinical denial and appeal procedures.
*Ability to investigate, analyze and apply billing, medical and reimbursement guidelines.
*Coding experience helpful.
*Ability to understand and analyze patient bills and medical records. Ability to lead, guide and motivate others.
*Ability to read, write and communicate effectively in English.
*Proficient with MS Office and able to learn new software rapidly. Experience with EMR (Epic) software desired.

Valid NC Driver's License: No
If driving a Wayne UNC Vehicle, must be 21 years old and MVR must be approved by Risk Management.

BO-205

Legal Employer: Wayne Health

Entity: Wayne UNC Health Care

Organization Unit: Health Information Mgmt

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Remote

Work Schedule: Day Job

Location of Job: WAYNE MED

Exempt From Overtime: Exempt: Yes