RN Clinical Appeals

Ensemble Health Partners

10d • Remote

About The Position

Thank you for considering a career at Ensemble! 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. Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference! O.N.E Purpose: Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results. The Opportunity: CAREER OPPORTUNITY OFFERING: Bonus Incentives Paid Certifications Tuition Reimbursement Comprehensive Benefits Career Advancement This position pays between $56,800.00 – $108,900.00 based on experience This individual will be responsible for reviewing denials and performing root cause analysis while partnering with the Denial Prevention Nurse Manager to improve process and reduce denials. The RN Clinical Appeals performs all appeals for clinically related claim denials across Ensemble Health Partners, or in a role that primarily assists with analyzing and reviewing records to prevent future denials, provide clinical records to payers, and prepare for provider-to-provider (P2P) reviews. Job duties include, but are not limited to, contacting insurance plans to determine reasons claims were denied, analyzing the claims and determining if appeal is necessary, preparing the appeal materials which may include correcting and resubmitting claims, gathering additional information, including reviews of medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner. In addition, the Specialist will work closely with other departments, such as Case Management, HIM, Physician Advisory, Clinical Denials, Denial Prevention, Accounts Receivable, Bedded Inpatient Authorization and Virtual Utilization review, to ensure denial trends and outcomes are communicated in a timely manner. The Specialist will perform these duties while meeting the mission of Ensemble Health Partners, as well as meeting the regulatory compliance requirements. Essential Job Functions: Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results. Contacting insurance plans to determine reasons claims were denied, analyzing the claims and determining if appeal is necessary, preparing the appeal materials which may include correcting and resubmitting claims, gathering additional information, including reviews of medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner. In addition, work closely with the Case Management Department and HIM Department to ensure denial trends and outcomes are communicated in a timely manner. This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Associates may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation. Employment Qualifications:

Requirements

• Current unrestricted license to practice nursing (LPN, RN)
• CRCR or other approved professional certification required with 9 months of date of hire
• 1 to 3 Years Job Experience
• Associates Degree or Equivalent Experience
• 2 years of denials, utilization review, or case management experience strongly preferred
• Proficient computer skills, including Microsoft Suite
• Experience in hospital operations, chart audit/review, and 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.
• candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require

Nice To Haves

• 4 year/ Bachelors Degree Preferred
• Registered Nurse (RN) or relevant discipline

Responsibilities

• reviewing denials
• performing root cause analysis
• partnering with the Denial Prevention Nurse Manager to improve process and reduce denials
• performing all appeals for clinically related claim denials across Ensemble Health Partners
• assisting with analyzing and reviewing records to prevent future denials
• provide clinical records to payers
• prepare for provider-to-provider (P2P) reviews
• contacting insurance plans to determine reasons claims were denied
• analyzing the claims and determining if appeal is necessary
• preparing the appeal materials which may include correcting and resubmitting claims
• gathering additional information, including reviews of medical records
• acting as a liaison between healthcare providers for any additional medical documentation or clarification
• submitting appeals in a timely manner
• work closely with other departments, such as Case Management, HIM, Physician Advisory, Clinical Denials, Denial Prevention, Accounts Receivable, Bedded Inpatient Authorization and Virtual Utilization review, to ensure denial trends and outcomes are communicated in a timely manner
• meeting the mission of Ensemble Health Partners
• meeting the regulatory compliance requirements

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: Entry Level
• Education Level: Associate degree
• Number of Employees: 501-1,000 employees