Clinical Denial Lead

Cleveland Clinic

17d•Remote

About The Position

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world. As a Clinical Denial Lead, you will assist Payer Denial Management Nurses and Coders with complex denials to support optimal clinical and reimbursement outcomes. In this role, you will oversee day-to-day operations and serve as a key resource for the team, maintaining quality, ensuring compliance, and supporting internal team management. Responsibilities include conducting vendor quality audits to ensure alignment with departmental standards, performing internal team audits to assess performance and identify improvement opportunities, and assisting with team management activities such as workload distribution, issue resolution, and training. A caregiver in this role works remotely from 8:00 a.m. to 5:00 p.m. Candidates must reside in Ohio or Florida to be considered for this role. A caregiver who excels in this role will: Provide management support when the supervisor is unavailable. Manage the day-to-day operations and act as the key information and education resource for the team. Work to develop enterprise-wide approaches to problem solving. Assist the Payer Denial Management Nurses and Coders with complex denials and promote the achievement of optimal clinical and reimbursement outcomes. Facilitate the appeals process, including monitoring appeal timeframes to minimize controllable loss write-offs. Review denials and write appeals for defined population. Identify, develop, and apply process improvement methodologies in evaluating and improving appeal outcomes. Collaborate with hospital departments identifying denial trends and process improvement opportunities. Function as the recognized expert serving as the clinical resource for the Coders, Physician Advisor and Nurses on the team. Lead meetings and participate on enterprise wide committees as needed. Serve as the preceptor for new hires. Work with leadership to align goals and visions.

Requirements

Licensed Registered Nurse (RN) in the State of Ohio, RHIT, RHIA, CCS or CPC Certified coder with background in professional coding and denials experience
Three years of Utilization Management or Coding experience
In-depth familiarity with third party billing requirements and regulations and writing appeals
Ability to communicate and exchange accurate information.
Ability to perform work in a stationary position for extended periods.
Ability to work with physical records or operate a computer or other office equipment.
In some locations, ability to travel throughout the hospital system.
In some locations ability to move up to 25 lbs.
Follows Standard Precautions using personal protective equipment as required for procedures.

Nice To Haves

Bachelor of Science in Nursing (BSN) or Bachelor’s degree in a related healthcare field
Certification in Case Management and InterQual
Expertise with InterQual and MCG disease management ideologies

Responsibilities

Provide management support when the supervisor is unavailable.
Manage the day-to-day operations and act as the key information and education resource for the team.
Work to develop enterprise-wide approaches to problem solving.
Assist the Payer Denial Management Nurses and Coders with complex denials and promote the achievement of optimal clinical and reimbursement outcomes.
Facilitate the appeals process, including monitoring appeal timeframes to minimize controllable loss write-offs.
Review denials and write appeals for defined population.
Identify, develop, and apply process improvement methodologies in evaluating and improving appeal outcomes.
Collaborate with hospital departments identifying denial trends and process improvement opportunities.
Function as the recognized expert serving as the clinical resource for the Coders, Physician Advisor and Nurses on the team.
Lead meetings and participate on enterprise wide committees as needed.
Serve as the preceptor for new hires.
Work with leadership to align goals and visions.