Specialist-Denial II RN

Baptist•Memphis, TN

About The Position

The Denial Mitigation-Appeal Specialist II RN supports the BMHCC revenue cycle by reviewing clinical information and supporting documentation for acute care inpatient services and other assigned account classes. The specialist analyzes payer denials, reviews patient records, prepares clinical timelines and account summaries, and determines appropriate next steps, including appeals, level-of-care downgrades, further escalation, clinical meetings, payer outreach, and coordination with physician clinics, coding, and billing. The role compiles clinical and financial information for payer submissions and may communicate with a Physician Advisor for additional clinical review. The specialist monitors accounts throughout the appeal process, escalates cases to management or payers when appropriate, and may defend appeals at payer hearings or clinical meetings. Remote work may be available after 90 days if productivity requirements and training goals are met, as determined by the Manager/Director of the Denial Mitigation Department. The position reports to the manager of the Denial Mitigation Department and performs other duties as assigned.

Requirements

Registered Nurse (RN) with five years of clinical experience in an acute healthcare setting.
Additionally, three to five years of experience in insurance provider work, auditing, or medical review involving denied claims, such as authorizations, claims review, patient billing, appeal writing, auditing, or denial management; or three to five years of case management experience or other related relevant experience.
Graduate of an accredited nursing program.
Training in nursing, case management, or denial management.
Familiarity with electronic medical records and claims or practice management systems.
Critical thinking and judgment, including the ability to appropriately apply standard criteria established by payers.
Excellent interpersonal, communication, and writing skills.
Advanced computer literacy, including accurate typing and data entry.
Strong analytical and problem-solving skills, including the ability to understand and troubleshoot interconnected data and denial processes.
Ability to meet department quality and productivity standards.

Nice To Haves

CCM certification.
CCS certification.

Responsibilities

Review payer denials and assess clinical records and supporting documentation to determine appeal actions and other account-resolution options.
Prepare clinical timelines and account summaries to guide next steps.
Compile, analyze, and submit relevant clinical and financial information to healthcare insurance providers in response to post-claim denials.
Prepare denial responses based on medical-record documentation, payer policies, NCDs, LCDs, and applicable state and federal rules and regulations.
Submit retro-authorization requests, reconsiderations, and appeals within payer-specific timeframes and according to contractual agreements and submission preferences.
Identify level-of-care downgrades, escalation options, and opportunities to resolve denials, including through corrected claims.
Coordinate with physician clinics to obtain supporting documentation and collaborate with coding and billing teams on appeals and denial resolution.
Work with Physician Advisors on medically complex appeals, hearings, or level-of-care issues.
Follow accounts through the appeal process and determine when to escalate issues to management or the payer.
Defend appeals in payer hearings or clinical meetings when required.
Review communications and correspondence and evaluate clinical information before appeal action to optimize reimbursement and resource utilization.
Review extenuating circumstances and other variables from point of entry through discharge when responding to technical authorization denials.
Build knowledge of external appeals, hearings, and escalation options outside the formal appeal process.
Report denial trends to management to support performance improvement and awareness of resources used in relation to reimbursement.
Meet department quality and productivity standards and complete assigned goals and projects within designated timeframes.