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Clinical Denial Specialist
2 months ago
- Conduct thorough research on payer denials related to medical necessity, coding, and other factors.
- Evaluate outpatient clinical denials against medical record documentation, coding, payer policies, and contracts to determine appeal viability.
- Compile supporting documentation by collaborating with internal departments and utilizing technology to draft detailed, customized appeal letters in accordance with Medicare, Medicaid, Commercial, and YNHHS policies and procedures.
- Ensure timely receipt and follow-up on appeals submissions until determination is made.
- Identify payer denial trends, triage discrepancies, and ongoing medical necessity, coding, or service issues, and collaborate or escalate for resolution.
- Provide educational opportunities derived from common themes discovered through the appeal process to prevent future denials.
- Track key denial data and develop metrics reports, including trend identification, action plans, and presentation to organizational committees as required.
- Communicate directly with payers and coordinate meetings with contracting and payers as needed to support appeals process.
- Two years of college or equivalent with familiarity with medical terminology and anatomy.
- Knowledge of coding, billing, and the revenue cycle.
- Working knowledge of human anatomy and physiology, disease process, and medical terminology.
- Three to five years of coding and/or billing experience required.
- Previous experience with governmental and managed care denial/appeal process, including familiarity with RAC.
- Certified Coding Specialist (CCS), Certified Coding Specialist Physician based (CCS-P) certification through the American Health Information Management Association (AHIMA) and/or Certified Professional Coder (CPC) or Certified Outpatient Coder (COC) through American Academy of Professional Coders (AAPC) or similar certification is required, or must be obtained within a year of hire.
This role supports the organization by reducing financial liability and recovering lost revenue for coding and medical necessity denials.
The OP Clinical Denial Specialist will work closely with colleagues within the organization and with managed care payers to resolve issues and expedite reimbursement on overturned appeals.
", "About Yale New Haven Health": "About Yale New Haven HealthYale New Haven Health is a comprehensive healthcare system that provides a wide range of medical services to the community.
Our organization is committed to delivering high-quality patient care and improving the health of our patients and the community we serve.
", "Contact Information": "Please note that this job description does not include contact information for the hiring manager or human resources department.
", "Language": "en"}