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Clinical Denials Specialist
2 months ago
We are seeking a highly skilled Clinical Denials and Appeals Specialist to join our team at NYU Langone Health. As a key member of our revenue cycle team, you will be responsible for managing clinical denials and appeals, conducting comprehensive reviews of clinical documentation, and formulating timely and defensible written responses.
Key Responsibilities- Manage clinical denials by conducting thorough reviews of clinical documentation and formulating written responses based on evidence-based medical necessity criteria, physician documentation, and medical policies of payors.
- Research and review payor denials related to referral, authorizations, level of care, and medical necessity, and formulate and submit appeal letters utilizing relevant clinical documentation, evidence-based medical necessity criteria, medical policies of payors, and community and national medical management standards and protocols.
- Collaborate with hospital departments, including Case Management, Health Information Management, and Clinical Documentation Improvement, to ensure accurate and timely clinical reviews.
- Document denials and appeals in tracking tools and provide reports to leadership as needed.
- Make recommendations for improvements to work queues and claim edits to reduce denials and improve efficiency.
- Review payor communications and identify potential issues related to medical policies and prior authorization requirements, escalating as necessary to clinical stakeholders, managed care contracting, and Revenue Cycle leadership.
- Maintain clinical expertise and trends in healthcare, reimbursement methodologies, and utilization management specialty areas through participation in professional organizations, seminars, and educational programs.
- 3-5 years of clinical RN experience, including 2 years of denial management or case management experience and 1-2 years of experience with reimbursement methodologies.
- Bachelor's degree in Nursing or a related clinical practice field.
- Current and valid NYS Registered Nursing License.
NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. We offer a competitive salary range of $81,325, and a comprehensive benefits package, including medical, dental, and vision insurance, retirement savings plan, and paid time off.
