Clinical Denials Coord

WVU Medicine

3d•Onsite

About The Position

Responsible for reporting, monitoring, and analyzing denials. Coordinates all referrals for further appeal to outside agencies based on department guidelines. Provides support and assistance to Revenue Cycle Leadership as directed. Coordinates all administrative activities surrounding management of clinical denials. Coordinates and performs appeals writing for RAC, Medicaid RAC, payer and other government denials. Provide process improvement initiatives through route cause analysis.

Requirements

Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
Three (3) years of healthcare clinical experience.
Strong letter writing skills.
Diverse clinical knowledge.
Effective communication skills.

Nice To Haves

Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN) or Diploma; Currently enrolled in a BSN program and BSN completion within three (3) years of hire.
Medical Management for Medicare and/or Medicaid populations.
Utilization Management experience.

Responsibilities

Completes clinical appeal writing for insurance denials.
Evaluates each patient medical record reviewing specific documents relating to patient treatment and billable charges, identifying services billed versus services documented as rendered.
Evaluates patient medical record versus the bill noting discrepancies in over-under and miss-billed items; correctly calculates the dollar total amounts for each discrepancy and submits necessary documents for adjustments.
Negotiates with external auditors regarding billing issues as needed to reach agreement on disputed items; provides appropriate supportive documentation for questioned charges.
Completes and submits audits documentation in a timely fashion and legible manner.
Communicates regularly with clinical and administrative personnel to obtain further supportive documentation for billed services.
Maintains current clinical knowledge through reading, attendance at seminars, clinical practice and informal sessions with other departments.
Provides timely information regarding bill defense problems to manager, and offers recommendations to eliminate the unnecessary loss of revenue.
Applies the medical necessity process to auditing to effectively maximize the hospital’s position in negotiation.
Participates in departmental projects and educational opportunities to enhance effectiveness of the audit unit.
Develops appropriate learning tools and objectives for presentations.
Coordinates all administrative activities with regard to denial management including: Collects all denial correspondence. Updates the denial database regularly to accurately reflect all denials received. Coordinates appeals process with Case Management, Patient Access, providers on appropriate accounts.
Aggressively appeals denials with payers to obtain maximum recovery of revenues.
Develops and/or coordinates training sessions ongoing for revenue cycle staff, clinical staff, etc. to maintain current practices with regard to payer denial activity.
Completes analysis and process improvement initiatives related to denials with clinical leaders in organization.
Prepares and distributes clinical denial reports as needed for various leaders and stake holders.
Assists with preparing and coordinating follow up activities to resolve organizational difficulties with regard to denials.
Identifies payer trends with regard to denials and communicates outcomes appropriately.
Attends all denial related meetings, as appropriate, to stay up to date on current organizational activities with regard to denials.
Attends training sessions, internal and/or externally, and researches the latest best practice trends in handling denials.