Clinical Denials Specialist
3 days ago
At Northwell Health, we are seeking a skilled Clinical Denials Specialist to join our team.
About the Role:
We are looking for a highly motivated individual with experience in Case Management, Appeals & Denials, and/or Utilization Review. The successful candidate will have a strong background in nursing, with a Bachelor's Degree in Nursing preferred. As a Clinical Denials Specialist, you will play a crucial role in reviewing corporate compliance audits, identifying coding issues, and developing strategies to improve denial rates.
Responsibilities:
- Review and respond to corporate compliance audits
- Serve as a resource for the health system on denial trends and coding issues
- Collaborate with physician advisors, payor representatives, and site case managers to facilitate appropriate level of care decisions and billing status
- Perform concurrent and retrospective utilization management using evidenced-based medical necessity criteria
- Conduct clinical reviews and formulate appeal letters to support appropriateness of admission and continued length of stay
- Ensure compliance with current state, federal, and third-party payer regulations
Requirements:
- Graduate from an accredited School of Nursing
- Bachelor's Degree in Nursing, preferred
- Current License to practice as a Registered Professional Nurse in New York State required
- Prior experience in Case Management, Appeals & Denials, and/or Utilization Review, highly preferred
Salary Information:
The estimated salary for this position is $80,000 - $110,000 per year, depending on experience and qualifications.
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