Clinical Denials Coordinator

UNC Health • Goldsboro, NC

386d

About The Position

The Clinical Denials Coordinator at UNC Health Care is responsible for overseeing and leading all clinical denial processes and audit activities. This role involves collaborating with a team to review denial requests, strategizing appeals, and providing clinical expertise in drafting audit appeals. The coordinator works closely with Physician Advisors and subject matter experts to ensure effective management of clinical denials and audits.

Requirements

• Graduate of an accredited program for professional nursing.
• Current North Carolina nursing licensure.
• 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.
• 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.
• Ability to understand and analyze patient bills and medical records.
• Proficient with MS Office and able to learn new software rapidly. Experience with EMR (Epic) software desired.

Nice To Haves

• Bachelor's degree in Nursing preferred.
• Coding experience helpful.
• Ability to lead, guide and motivate others.

Responsibilities

• Provides leadership, clinical expertise and organization to the Denials Management Team.
• Stays up to date and proactive with all ongoing information, rules and regulations, Medicare and other payor regulations.
• Reviews all denials and is key point person for assigning team review.
• Reviews and documents findings on all medical necessity and status denials.
• Works closely with Patient Financial Services for issues related to reimbursement, denials, status, etc.
• 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.
• Conducts case studies for those complex denials in order to plan appeal strategies and to educate peers.
• Conducts pertinent discussions with auditors and follows appropriate appeals process within established timeframes.
• Reviews and responds weekly to status issue queries from coders, Quality and other entities.
• Responsible for summary reports of Wayne UNC Health Care denials and presents denials summary to IM/UR committee at least quarterly.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree
• Number of Employees: 10,001+ employees