Clinical Denials Specialist

4 weeks ago

Tampa, Florida, United States SNI Companies Full time
Job Title: Clinical Denials Specialist

Job Summary:

We are seeking a highly skilled Clinical Denials Specialist to join our team at SNI Companies. As a Clinical Denials Specialist, you will be responsible for conducting a comprehensive review of insurance denials and working with our Clinical Denials Nurses and Coding Denials Specialists to compile appropriate documentation and medical records to submit appeals or corrected claims in a timely manner.

Key Responsibilities:

* Formulate strategy for prioritizing cases and maintain aging within appropriate ranges with minimal direction or intervention from Leadership
* Review account history, remit, payer history, and state requirements to determine appropriate challenge and appeal strategy
* Gather and fill out all special appeal or payer required forms
* Compose and submit all required documentation (including appropriate medical records to support medical necessity) for a reconsideration, appeal, or retro authorization to the insurance carrier via payer portal, fax, etc...
* Document and summarize all rationale for all appeals in EPIC
* Follow up on submitted appeals through payer portal or phone calls to the payer
* Escalate issues in accordance with the department escalation policy
* Use critical thinking skills to resolve aged and problematic accounts
* Follow account to timely resolution to include appropriate financial adjustment
* Interface with other departments to satisfactorily resolve issues related to appeals and initial denials
* Communicate with Pre-Cert team and/or medical office personnel to obtain pertinent information
* Maintain a thorough understanding of operations and business unit processes/workflows including, but not limited to authorizations and referral requirements, and in/out-of-network insurances
* Maintain payer portal access and utilize said portals to assist in reviewing commercial medical policies or LCD and NCD (local and national coverage determination) rules
* Maintain a current knowledge of CMS rules and regulations relating to the grievance and appeal processes
* Maintain working knowledge of applicable insurance carriers' timely filing deadlines, claims submission processes, and appeal processes and escalate timely filing requests to Leadership
* Collaborate with Clinical Denials Nurse, Coding Denials Specialists, and Leadership in high-dollar claim denial review
* Monitor for denial trends, work collaboratively with the revenue cycle teams to reduce revenue loss
* Help identify issues from denials and appeals that might be avoided on future claims
* Assist department leadership with research, analysis and special projects
* Attend necessary payer meetings to escalate denials issues
* Participate in huddle meetings and sharing the details of cases worked

Requirements:

* Two years' recent experience in healthcare revenue cycle or prior authorizations for inpatient/outpatient, hospital/physician
* Experience in healthcare claims processing and proficiency with medical billing and remittance forms and processes, including 835 and 837 files, and UB04 and CMS-1500 (HCFA) forms
* Experience in managing and appealing authorization or medical necessity denials
* Medical terminology

Why Join Us:

At SNI Companies, we are committed to providing our employees with a challenging and rewarding work environment. We offer competitive salaries, comprehensive benefits, and opportunities for professional growth and development.

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