Position Highlights:
Responsible for the administration and coordination of the denials review and appeals management processes that includes denials management, claims recovery, and denial root cause analysis.
The Ideal Candidate:
- Experience in oncology nursing, utilization review, quality management, and/or recent case management and Soarian experience.
Responsibilities:
- Submit medical necessity appeals electronically and/or mail. Follow up electronically and/or telephonically with payers for claim and appeal status.
- Make a preliminary determination whether denial can be overturned and if initial or secondary appeals should be submitted.
- Research and prepare appeal responses to clinical denials.
- Review of clinical denials including identification of root cause.
- Resolve clinical denials which include researching and reviewing payer guidelines, writing and submitting appeals with supporting documentation if required.
- Identifies coding, billing, or reimbursement errors/discrepancies with the denial or aging claim in order to escalate to the denial recovery supervisor.
- Evaluate denied dollars for both contracting and non-contracting insurance companies; and resolution of reimbursement discrepancies.
- Resolution of denials for medical necessity, utilization review, pre-certification, authorization, and concurrent review to include writing appeals and responsible for conducting and preparing responses.
- Track and trend denials issues for escalation to leadership for process improvement.
Credentials and Qualifications:
- Bachelors Degree plus a minimum of five (5) years healthcare experience and RN required
- (OR) “in lieu of” a Bachelor’s degree you must have an Associates degree plus a seven (7) years healthcare experience preferably in Nursing and RN required.
*_Accommodation: LPN’s currently in the role of Clinical Denial Specialist will be given a specified time frame (2 years) to obtain the RN licensure _ “in lieu of” Associate’s, a H.S. Diploma with two (2) years of additional related claims/collection experience maybe considered.
Location: H. Lee Moffitt Cancer Center & Research Institute · Denials
Schedule: Full Time, Day Shift, Mon – Fri 7a – 3:30p