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Clinical Denials Specialist
2 months ago
NYU Langone Health is seeking a highly skilled Clinical Denials and Appeals Specialist to join our team. As a key member of our clinical denials and appeals team, 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, and 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, including Case Management, Health Information Management, and Clinical Documentation Improvement, as clinical reviews are performed.
- Collaborate with Physician Advisors to appropriately identify clinical denials that require escalation.
- Document in appropriate tracking tools for maintenance and distribution of reports as needed by leadership.
- Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up and root cause resolution.
- Make recommendations for additions, revisions, or 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, and 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.
- Attend enterprise hospital meetings under the direction of the Clinical Denials and Appeals Manager.
- 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.
- Experience with Interqual and/or Milliman Disease Management Ideologies.
- Strong communication (verbal and written) and interpersonal skills.
- Ability to communicate with multiple levels of the organization, including Senior Leadership, Physicians, Directors, Clinical, and Support Staff.
- Demonstrates critical thinking and analytical skills.
- Ability to work collaboratively in a team environment.
- Demonstrates the ability to handle multiple assignments and carry out work independently with minimal supervision.
- Demonstrates responsibility for professional development.
- Ability to work a flexible schedule to ensure compliance with deadlines.
- Proficient with Microsoft applications and working knowledge of EPIC and other hospital-based clinical computer systems.
- Experience preparing appeals for clinical denials.
- Certification in Clinical Documentation Improvement.
NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information, or any other factor which cannot lawfully be used as a basis for an employment decision.
