Denials RN Coordinator

Ensemble Health Partners

1d • Remote

About The Position

Ensemble is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country. The Denials RN Coordinator prepares appeals for clinical and technical claim denials across all client hospital facilities. This role involves understanding insurance contract terms, reviewing claim denials and underpayments to determine if additional payment amounts can be expected, analyzing medical records to determine if a member or an Independent Review organization (IRO) appeal is necessary, and understanding payer medical policy guidelines. The coordinator is responsible for preparing IRO appeal documentation, which may include correcting and resubmitting claims, gathering additional information, reviewing medical records, acting as a liaison between healthcare providers for additional medical documentation or clarification, and submitting provider, member, and IRO/ALJ appeals in a timely manner. The position requires knowledge and understanding of ERISA compliance laws, healthcare provider and member's legal rights regarding member appeal and grievance processes, and ensures compliance with HIPAA regulations. The Denials RN Coordinator will also work closely with the Clinical Appeal team and Case Management Department to ensure denial trends and outcomes are communicated in a timely manner, and will serve as a mentor and provide necessary training and education to Clinical Denial and Underpayment team members. All duties must be performed while meeting Ensemble principles and regulatory compliance requirements.

Requirements

• Legally Required License: Registered Nurse RN
• 5 to 7 years Job Experience
• Knowledge and understanding of ERISA compliance laws, healthcare provider and member's legal rights regarding member appeal and grievance processes.
• Ensures compliance with HIPAA regulations.
• Internal Candidate must have met 100% productivity and 100% Quality Assurance, in the previous 3 months.
• Must pass typing test of 45 words per minute (error adjusted)

Nice To Haves

• 4 year/ Bachelors Degree
• 2 years of denials, utilization review, or case management experience strongly preferred
• 5+ Years of experience in: Revenue Cycle
• 5+ Years of experience in: Legal nurse consulting
• 5+ Years of experience in: Chart audit/review
• 5+ Years of experience in: Provider relations
• Demonstrated advanced usage of AI and the management of teams using AI to lean in to process and technological improvements, to include the exploration, experimentation, and application of AI.

Responsibilities

• Prepare appeals for clinical and technical claim denials across all client hospital facilities.
• Understand insurance contract terms.
• Review claim denials and underpayments to determine if additional payment amounts can be expected.
• Analyze medical records and determine if a member or an Independent Review organization (IRO) appeal is necessary.
• Understand payer medical policy guidelines.
• Prepare IRO appeal documentation which may include correcting and resubmitting claims, gathering additional information, reviewing medical records.
• Act as a liaison between healthcare providers for any additional medical documentation or clarification.
• Submit provider, member and IRO/ALJ appeals in a timely manner.
• Ensure compliance with HIPAA regulations.
• Work closely with the Clinical Appeal team and Case Management Department to ensure denial trends and outcomes are communicated in a timely manner.
• Serve as a mentor and provide necessary training and education to Clinical Denial and Underpayment team members.
• Review complex claims and escalate clinical or technical claim denials for potential provider, member level or IRO/ALJ appeal.
• Extensive review of medical records for medical necessity criteria.
• File written letters of appeal on denied claims.
• File complaints with state Department of Insurance.
• Identify trends in payment discrepancies amongst payors.
• Perform other duties as assigned.

Benefits

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement
• Associate Benefits – We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.
• Our Culture – Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.
• Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.
• Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company.

What This Job Offers

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