Clinical Denial Specialist

Franciscan Alliance, Inc.

2d • $67,142 - $92,331 • Remote

About The Position

The Clinical Denial Specialist II functions as a hospital liaison to appeal denied claims for Medicare, Medicaid, Managed, and Commercial insurance. The role conducts detailed retrospective reviews of patient medical records in EPIC, analyzing and compiling data for additional documentation requests and claim denials. It uses identified trends and patterns to support process improvement.

Requirements

• Bachelor's degree in Nursing, or an Associate degree in Nursing with 5 years of nursing experience.
• Active Indiana RN license.
• 3 years of denial-related experience.

Nice To Haves

• 5 years of nursing or case management experience.

Responsibilities

• Develop reports.
• Review governmental contractor responses.
• Identify underlying root causes for potential denials and work closely with departments and Clinical Documentation Integrity to reduce denials.
• Write appeals and ensure they are filed promptly and in a timely manner for Medicare, Medicaid, Managed, and Commercial payors.
• Audit medical documentation for adherence to insurance and CMS guidelines relating to inpatient or observation services and other denial issues.
• Use knowledge of inpatient criteria to establish medical necessity letters.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level