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Clinical Denials Specialist RN
2 months ago
NYU Langone Health is seeking a highly skilled Clinical Denials Specialist RN to join our team. As a Clinical Denials Specialist RN, you will be responsible for managing clinical denials by conducting comprehensive reviews of clinical documentation and formulating timely and defensible written responses based on clinical documentation, evidence-based medical necessity criteria, physician documentation, and medical policies of the payor.
Key Responsibilities:- Research and review payor denials related to referral, authorizations, level of care, and medical necessity
- Formulate and submit appeal letters utilizing relevant and effective clinical documentation, evidence-based medical necessity criteria, medical policies of the payer, and community and national medical management standards and protocols
- Assist with the coordination and collaboration with hospital departments (Case Management, Health Information Management, and Clinical Documentation Improvement, Inpatient and Outpatient Revenue Services, etc.) as clinical reviews are performed
- Document in appropriate tracking tools for maintenance and distribution of reports as needed by leadership
- Makes recommendations for additions/revisions/deletions to work queues and claim edits to improve efficiency and reduce denials
- Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalate potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership, as appropriate
- Maintain clinical expertise and trends in healthcare, reimbursement methodologies, and utilization management specialty areas by participating in professional organizations, seminars, and educational programs
- 3-5 years of Clinical RN experience, including 2 years of Denial Management or Case Management or related experience and 1-2 years of current experience with reimbursement methodologies
- Bachelor's Degree in Nursing or other Clinical Practice field
- Current and valid NYS Registered Nursing License
NYU Langone Health provides its staff with far more than just a place to work. We offer a comprehensive benefits package, including medical, dental, and vision coverage, as well as a 403(b) retirement plan and paid time off. We are an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment.
