Clinical Denial Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Serve as a liaison for the hospital to appeal denied claims from Medicare, Medicaid, Managed, and Commercial insurance.

• Perform thorough retrospective evaluations of patient medical records within the EPIC system.

• Gather and analyze data for additional documentation requests and claim denials.

• Create and develop comprehensive reports.

• Review responses from governmental contractors.

• Identify the underlying causes of potential denials and collaborate with departments and Clinical Documentation Integrity for process enhancements.

• Draft and submit appeals in a timely manner.

• Audit medical documentation to ensure compliance with insurance and CMS standards for inpatient and observation services.

• Prepare medical necessity letters based on inpatient criteria.

⛳️ Requirements

• A Bachelor's degree in Nursing or an Associate degree in Nursing with a minimum of 5 years of nursing experience is required.

• An active Indiana RN license is mandatory.

• At least 3 years of experience related to denials is required.

• 5 years of experience in Nursing or Case Management is preferred.

• Familiarity with inpatient criteria is essential.

• Understanding of Medicare, Medicaid, Managed, and Commercial insurance requirements is necessary.

• Experience with EPIC and conducting medical record reviews is required.

• Must be able to work Monday–Friday from 8:00 a.m. to 4:30 p.m. EST.

🏝️ Benefits

• A wide range of comprehensive benefit offerings for eligible employees.