The Opportunity:

CAREER OPPORTUNITY OFFERING:

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement
• This position pays between $56,800.00 – $108,900.00 based on experience

The RN Clinical Appeals performs all appeals for clinically related claim denials across Ensemble Health Partners, or in a role that primarily assists with analyzing and reviewing records to prevent future denials, provide clinical records to payers, and prepare for provider-to-provider (P2P) reviews. Job duties include, but are not limited to, contacting insurance plans to determine reasons claims were denied, analyzing the claims and determining if appeal is necessary, preparing the appeal materials which may include correcting and resubmitting claims, gathering additional information, including reviews of medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner. In addition, the Specialist will work closely with other departments, such as Case Management, HIM, Physician Advisory, Clinical Denials, Denial Prevention, Accounts Receivable, Bedded Inpatient Authorization and Virtual Utilization review, to ensure denial trends and outcomes are communicated in a timely manner. The Specialist will perform these duties while meeting the mission of Ensemble Health Partners, as well as meeting the regulatory compliance requirements.

Essential Job Functions:

• Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.
• ​Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.
• Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results.
• ​Contacting insurance plans to determine reasons claims were denied, analyzing the claims and determining if appeal is necessary, preparing the appeal materials which may include correcting and resubmitting claims, gathering additional information, including reviews of medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner.In addition, work closely with the Case Management Department and HIM Department to ensure denial trends and outcomes are communicated in a timely manner.

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Associates may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation.

Employment Qualifications:

• Current unrestricted license to practice nursing (LPN, RN)
• CRCR or other approved professional certification required with 9 months of date of hire

Job Experience:

• 1 to 3 Years

Desired Education Level:

• Associates Degree or Equivalent Experience

Preferred Area of Study:

• Nursing

Other Preferred Knowledge, Skills and Abilities:

• 4 year/ Bachelors Degree        
• Preferred Minimum Education - Specialty/Major: Registered Nurse (RN) or relevant discipline        
• Minimum Years and Type of Experience: 2 years of denials, utilization review, or case management experience strongly preferred

Other Knowledge, Skills and Abilities Required:

• Proficient computer skills, including Microsoft Suite        
• Experience in hospital operations, chart audit/review, and provider relations.

• Demonstrated advanced usage of AI and the management of teams using AI to lean in to process and technological improvements, to include the exploration, experimentation, and application of AI.

• This is a remote position; however, candidates must be willing and able to travel to and work onsite at client, temporary, or corporate office locations as business needs require.