Clinician, Denials Prevention - Remote

Med-Metrix•Garden City, NY

2d•$80,000 - $85,000•Remote

About The Position

The Clinician, Denials Prevention, uses their clinical and administrative skills to analyze denials and appeal outcomes. They share opportunities with clients to reduce first pass denials by ensuring proper patient status, authorizations, clinical documentation opportunities, staff education, and collaboration with other departments.

Requirements

Bachelor’s degree in a health-related field; 2 years of experience may be considered in lieu of a degree in addition to the required experience.
Two years of recent experience in hospital case management, hospital prior authorization, or utilization management
Experienced in medical chart review
Experience with medical and insurance terminology, CPT, ICD coding structures, and billing forms
Proficiency in Microsoft Office Suite
Strong interpersonal skills, ability to communicate well at all levels of the organization
Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
High level of integrity and dependability with a strong sense of urgency and results oriented
Excellent written and verbal communication skills required
Gracious and welcoming personality for customer service interaction
Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes.

Nice To Haves

LPN or RN preferred.
Claim-related appeal writing experience preferred
Experience with MCG and/or InterQual guidelines preferred

Responsibilities

Maintain the integrity of information in each appeal produced
Review a high volume of written appeals to ensure information is medically accurate
Research payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment
Make recommendations for workflow revisions to improve efficiency and reduce denials
Present case studies and recommendations to clients and impacted stakeholders
Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate
Identify opportunities for process improvement and actively participate in process improvement initiatives, internally and externally
Other duties as assigned
Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
Understand and comply with Information Security and HIPAA policies and procedures at all times
Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties