Clinical Denial Analyst

Larkin Community Hospital • South Miami, FL

31d

About The Position

The RN Denial Analyst is responsible for reviewing denial claims, submitting reconsiderations or appeals. Reporting to the Revenue Cycle Director, this role is responsible to optimize the financial outcomes of the hospital-based revenue cycle through maintaining a low denial rate and high reimbursement rate. Initiates a root cause analysis of denied payment through comprehensive means including but not limited to: research of patient stays and treatment, review of payer contracts, analysis of historical denials, appeals and their outcomes, emerging trends in payer practices and requirements. The RN denial analyst is considered an expert in denial management and ensures all denied claims are accurately worked from a technical/ billing perspective. Working in collaboration with the different revenue cycle departments through the health system to establish best practice solutions to maximize reimbursement and minimize organizational write-offs.

Requirements

• Registered nurse (RN), or Bachelor’s degree in nursing or equivalent knowledge.
• Three or more year’s denials management, appeals, clinical documentation experience.
• Prior experience in claims processing and/or billing and collections.

Responsibilities

• Tracks and analyzes denial data to identify, recommend, and implement opportunities to secure legitimate revenue for the organization. Identifies trends or patterns that impact payment optimization, and collaborates with departments to establish action plans, initiatives, and policies to reverse negative denial patterns.
• Prepare and defends level of care and medical necessity appeals.
• Generates, and audits various revenue, financial, statistical and/or quality reports surrounding the denial prevention area of focus.
• Supporting claims denials reductions and increased revenues through process redesign, root cause analysis and development of metric reports.
• Analyzes and reviews third party payer denial of medical claims and develops and executes strategies to decrease denials system wide to optimize revenue.
• Identifies revenue opportunities and provides appropriate investigation, follow up and resolution. Implements plans and partners with Managed Care Contracting to ensure proper adherence to contracts that does not affect revenue generation.
• Prepares clear and concise data reports to for senior leadership and others as required.

What This Job Offers

• Job Type: Full-time
• Number of Employees: 1,001-5,000 employees