Specialist Clinical Denial

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Job Type:

Regular

Scheduled Hours:

40

💙 Why You’ll Love Working with St. Elizabeth Healthcare

At St. Elizabeth Healthcare, every role supports our mission to provide comprehensive and compassionate care to the communities we serve. For more than 160 years, St. Elizabeth Healthcare has been a trusted provider of quality care across Kentucky, Indiana, and Ohio. We’re guided by our mission to improve the health of the communities we serve and by our values of excellence, integrity, compassion, and teamwork. Our associates are the heart of everything we do.

 

🌟 Benefits That Support You

We invest in you — personally and professionally.

Enjoy:

- Competitive pay and comprehensive health coverage within the first 30 days.

- Generous paid time off and flexible work schedules

- Retirement savings with employer match

- Tuition reimbursement and professional development opportunities

- Wellness, mental health, and recognition programs

- Career advancement through mentorship and internal mobility

Job Summary:

Reviews and resolves denials received post-service requiring clinical input or interpretation.

The Clinical Denials Specialist is responsible for analyzing, resolving, monitoring and reporting clinical denials to Denials Unit Manager as appropriate. The Clinical Denial Specialist is responsible for appeals and follow-up on clinical denials escalated through a work queue, providing appropriate denial information to be submitted to departments to ensure systems, processes and measures of effectiveness (e.g. Remediation action plans), are created and implemented to resolve root cause issues and reduce/ eliminate denials. The Clinical Denial Specialist should remain in full compliance with all departmental, institutional and regulatory policies and procedures at all times. The roles and responsibilities of this job support the mission, vision, values and strategies of St. Elizabeth Healthcare.

Demonstrate respect, dignity, kindness and empathy in each encounter with all patients, families, visitors and other employees regardless of cultural background.

Job Description:

Job Duties: Performs extensive follow-up, completes appeals and referrals to other stakeholders, when appropriate. Investigates and/or ensures that questions and requests for information are responded to in a timely and professional manner to ensure resolution of outstanding accounts. Performs ongoing monitoring of denials accounts worked, as necessary, to ensure maximization of collection dollars by providing appropriate follow-up and documenting actions taken. Utilizes all appropriate systems to effectively research accounts and complete steps to submit information necessary to process or appeal accounts. Completes follow-up with patients, as necessary, to obtain additional information. Prepares necessary documentation to submit appeals to payers when payment is denied. Complete all necessary outgoing calls and answer incoming calls, as appropriate. Makes revisions or changes to insurance information, as appropriate. Requests the rebilling accounts as necessary. Complete and / or request adjustments to an account, as appropriate, based on adjustment thresholds. Reviews, works and reports (with accuracy) all accounts that have aged more than the specified grace period stipulated in the policies and / or contracts. Documents follow-up on patient accounts appropriately. Tracks and reports violation of prompt pay / adjudication terms by payers. Follows up proactively with payers to provide necessary additional documentation for patient accounts that have been reviewed by payers and awaiting documentation to determine adjudication. Prioritizes work/resources to accomplish objectives and meet deadlines. Maintains compliance with federal, state and local regulations and HIPPA. Maintains the privacy and security of all confidential and protected health information; job duties warrant a “high” level of computer system access (all necessary areas) to patient information ONLY for those job functions as outlined in this job description; uses and discloses only that information which is necessary to perform the function of the job. Interfaces with other key internal and external staff to obtain necessary information to address payment variance, management of issues or requests. Reports issues and trends to appropriate management personnel and works collaboratively to develop solutions. Participates in all educational activities and demonstrates personal responsibility for job performance. Willingness to participate and share expertise on projects, committees and other activities, as deemed appropriate. Meets or exceeds expectations for data quality, customer service, payment variance management turnaround and productivity. Maintains satisfactory attendance record and punctuality record as set forth by St. Elizabeth Healthcare and departmental policies. Consistently demonstrates a positive and professional attitude at work. Performs other duties as assigned. MINIMUM REQUIREMENTS Education, Credentials, Licenses: If eligible, must have a Compact (multi-state) License in their primary state of residence. Licensed to practice nursing in the state where work is being performed Specialized Knowledge: Clinical Skills to include the ability to read and interpret medical records. Demonstrates proficiency in Microsoft Office applications and others as required. Demonstrates knowledge and understanding of organizational policies and procedures. Knowledge of insurance regulations, payment guidelines and policies and the ability to communicate and work with payors to get accounts resolved and paid accurately. Extensive knowledge of Medicare and Medicaid regulations. Knowledge of Third Party claim filing, contract reimbursement and other insurance guidelines. Knowledge of UM/Quality concepts Demonstrate analytical and problem solving skills Kind and Length of Experience: 5 years nursing experience

FLSA Status:

Exempt

Right Career. Right Here. If you're looking for the right careers in healthcare, the right place to be is at St. Elizabeth. Join us, and you'll take pride in the level of care we offer our community.