Schedule: Full time
Shift: Day (United States of America)
Address: 900 HOPE WAY
City: ALTAMONTE SPRINGS
State: Florida
Postal Code: 32714
Job Description: - Reviews and appeals clinical denials across all service lines system-wide
- Researches account histories, patient encounters, payer portals, and payment records to determine appropriate appeal strategies
- Evaluates denial types including but not limited to charge audit, clinical validation, experimental services, payer policy denials, level of care, NICU, and readmissions
- Executes charge corrections and prepares accounts for rebilling as appropriate
- Collaborates with pre-access, patient financial services, revenue integrity, utilization management, and clinical departments to gather supporting documentation
- Provides reports, education, and training on clinical denial trends and recommended remediation strategies
- Educates stakeholders on proper documentation, payer processes, and policies with a denial prevention focus
- Drafts and submits written and verbal appeals using clear, concise clinical terminology
- Researches root causes, collects supporting documentation, and adjusts accounts based on internal and external findings
- Utilizes multiple IT systems to compile comprehensive clinical and financial information for appeals
- Escalates identified claim issues and trends to appropriate leadership or payer contacts
- Performs other duties as assigned
Knowledge, Skills, and Abilities: - Understanding of charge capture, revenue integrity concepts, and defense of appropriately assigned charges on appeal [Required]
- Extensive understanding of CPT, HCPCS, ICD, UB-04 Revenue Codes, modifiers, billing regulations, and guidelines for government and commercial payers [Required]
- Ability to defend the clinical validation of assigned diagnoses [Required]
- Experience with utilization review and understanding of Inpatient vs. Observation assignment using MCG and InterQual [Required]
- Ability to navigate the electronic medical record, understand services performed, and correlate services to charges [Required]
- Strong critical thinking and problem-solving skills with ability to multi-task and reprioritize in a fast-paced environment [Required]
- Ability and willingness to continuously learn new concepts and skills to navigate the ever-changing reimbursement/denials landscape [Required]
- Self-starter with ability to work independently with limited day-to-day oversight [Required]
- Strong written communication and grammatical skills to craft individualized appeal letters based on patient severity, intensity of service, denial type, and applicable regulations [Required]
- Proficiency in Microsoft Suite applications, specifically Word, Excel, and Outlook [Required]
- Ability to utilize Microsoft Teams for communication, meetings, and video presence [Required]
- Technical proficiency to independently set up computer systems, maintain reliable internet service with backup plan, and troubleshoot technical issues [Required]
- Comfort with interpreting payer contractual language [Required]
- Proficiency with Epic EHR system [Preferred]
- Comfort with interpreting payer contractual language [Preferred]
Education: - Bachelor's of Nursing [Required]
Work Experience: - 2+ years of clinical denials or utilization management experience [Required]
- 3+ years' experience as a Registered Nurse (RN) in an acute clinical setting [Required]
- 1+ year in ICU and/or Medical Surgical Unit [Required]
- 1+ year of demonstrated proficiency in appeals writing for all hospital services. [Required]
Licenses and Certifications: - Registered Nurse (RN) [Required]
- Certified Revenue Cycle Rep (CRCR) [Preferred]
Physical Requirements: (Please click the link below to view work requirements)
Physical Requirements - https://tinyurl.com/23km2677
Pay Range:$70,682.60 - $131,480.21
Background Screening Requirement (Florida Law) Certain positions are subject to
Florida Level 2 background screening, including fingerprinting, as required by state law.
Applicants may review general information about Florida's background screening requirements at the
Florida Care Provider Background Screening Clearinghouse:
https://info.flclearinghouse.com/
