Clinical Appeals Specialist II-Hybrid

Mayo Clinic • Rochester, MN

13d • Hybrid

About The Position

This is a hybrid position and must be located within 100 miles of any of the Mayo Clinic campuses for on-site expectations based on business needs. Primary duties may include, but are not limited to, responsibility for reviewing assigned clinically related denials, payer audits, and payer correspondence as well as preparation of relevant appeal submission or audit responses. Utilizes clinical expertise and critical thinking in the evaluation of medical records against appropriate criteria and contract requirements and utilizes appropriate communication style to appeal or defend medically denied claims. Is a liaison and resource to revenue cycle, case management and practice stakeholders in defending clinically denied claims and providing relevant feedback to key stakeholders on denial prevention opportunities.

Requirements

• Associates Degree
• 3 years of relevant nursing experience
• Current active unrestricted RN license.
• Ability to effectively utilize Microsoft Office Suite
• Basic data entry skills
• Excellent verbal, written and interpersonal communication skills
• Ability to balance multiple demands and respond to time constraints
• High-level skills in organization
• Problem solving and analytical skills

Nice To Haves

• Advanced knowledge of ICD-10-CM/PCS coding conventions, DRG reimbursement methodology, and clinical validation principles, with demonstrated ability to interpret Coding Clinic guidance and Medicare IPPS regulations to support accurate DRG assignment and defend coding-related denials.
• Healthcare Financial Management Association (HFMA) Certification
• CCDS or CDIP Certification
• Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization
• Knowledge and use of discharge planning, case management, utilization review, and levels of care criteria.
• Familiarity with Medicaid and Medicare claims denials and appeals processing and regulatory requirements.
• Knowledge and use of payer medical policy and Medicare LCD/NCD criteria.
• Knowledge of billing and coding requirements.
• Experience utilizing Milliman Care Guidelines and InterQual Criteria.
• Knowledge of current NCQA/URAC standards.
• Knowledge and experience applying 2-Midnight Rule Criteria.
• Knowledge and experience in Epic.

Responsibilities

• Reviewing assigned clinically related denials, payer audits, and payer correspondence.
• Preparation of relevant appeal submission or audit responses.
• Utilize clinical expertise and critical thinking in the evaluation of medical records against appropriate criteria and contract requirements.
• Utilize appropriate communication style to appeal or defend medically denied claims.
• Serve as a liaison and resource to revenue cycle, case management and practice stakeholders in defending clinically denied claims.
• Provide relevant feedback to key stakeholders on denial prevention opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree