Clinical Denials Prevention Specialist

Datavant is a pioneering data platform company, recognized as the leader in health data exchange. We envision a future where every healthcare decision is informed by the right data, precisely when and how it is needed.

Our platform is backed by the largest and most varied health data network in the U.S., ensuring that data is secure, accessible, and actionable to drive better health outcomes. We are trusted by prominent life sciences companies, government organizations, and those involved in delivering and financing healthcare.

By joining Datavant, you are becoming part of a high-performing, values-driven team committed to overcoming some of healthcare's toughest challenges with innovative technology solutions. Our team members bring diverse professional, educational, and personal experiences to help realize our ambitious vision for healthcare.

The Denials Prevention Specialist plays a crucial role in safeguarding the utilization of available health services by reviewing admissions for medical necessity and ensuring the need for continued care in inpatient settings or discharge to alternate levels of care. This will be achieved using established medical necessity criteria along with clinical expertise.

The ideal candidate will be a Licensed Practical Nurse or Registered Nurse experienced in DRG downgrade denials and proficient in appeal writing for inpatient admissions, with a solid understanding of clinical criteria resources and payer guidelines.

Your responsibilities will include:

• Timely and accurate referrals/appeal determinations.

• Utilizing Milliman Care Guidelines and/or Interqual during assessments.

• Crafting appropriate language for appeal letters and identifying cases for medical director review.

• Selecting contracted providers correctly.

• Identifying eligibility and healthcare plans accurately.

• Meeting compliance with turnaround time requirements as set by facility standards and/or CIOX Health standards.

• Collaborating with providers and health plan Medical Directors for efficient authorizations and denial reversals.

• Maintaining confidentiality of all files, documents, and records.

• Achieving or exceeding production and quality metrics.

• Participating in all mandatory meetings and trainings, along with other job-related tasks as delegated by management.

The ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in DRG downgrade denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payer guidelines is essential.

Your qualifications should include:

• A minimum of two (2) years of managed care experience in UM/CM/CDI preferred.

• Knowledge of CMS, State Regulations, URAC and NCQA preferred.

• Familiarity with ICD10 and CPT coding is a plus.

• Proficient in computer skills, including Word, Excel, and Outlook; experience in health plan medical management documentation systems is an advantage.

Minimum Education: LVN/LPN

• Preferred Education: BA or BS in Nursing.

• Minimum Experience: 3 to 5 years acute care experience.

• 2 years Health Plan or Acute Care UR/CM experience.

• Preferred Experience: 5 years in acute care or health plan UR/CM with at least 1 year in ICU/ER.

We are dedicated to building a diverse team of professionals who foster a high-performance culture where every member feels valued and supported. We proudly uphold Equal Employment Opportunity standards, ensuring all qualified applicants receive fair consideration regardless of race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, or other legally protected status.

Our compensation strategy focuses on being competitive and fair, using industry benchmarks to guide salary ranges for this position, which reflect individual skills and experience levels. The estimated pay range for this role is $22 - $45 per hour.

Please note that this job is not eligible for employment sponsorship. To ensure a safe working environment, many of our clients mandate post-offer health screenings and various vaccinations, including COVID-19 and flu shots. Exemptions may be available and will be assessed on a case-by-case basis.

At Datavant, we are committed to a discrimination-free work environment. Our Equal Employment Opportunity policy guarantees all qualified applicants consideration for employment without regard to legally protected statuses. We encourage applicants to complete voluntary demographic questions at the end of the application to help us improve our recruitment efforts. All responses will remain anonymous and will not impact your application.

If you require any reasonable accommodations during the application process, please request them through our HR team. We value your privacy, and you can review our Privacy Policy for details on how we handle your data.