NYU Winthrop is a 591-bed university-affiliated medical center, which offers sophisticated diagnostic and therapeutic care in virtually every specialty and subspecialty of medicine and surgery. We are a major regional healthcare resource with a deep commitment to medical education and research, offering a full complement of inpatient and outpatient services.
We have an exciting opportunity to join our team as a Specialist, Clinical Denials & Appeals.
In this role, the successful candidate under the general supervision of the Director, the Clinical Denials and Appeals Specialist performs advanced level work related to Clinical Denial Management. Responsible for managing clinical denials by conducting a comprehensive review of clinical documentation and formulating a timely and defensible written response based on clinical documentation, evidence based medical necessity criteria, physician documentation and medical policies of the payor. Communicates identified denial trends and patterns to Clinical Denials and Appeal Manager. Works to review, evaluate and improve the enterprise clinical denial and appeal process.
- Researches and reviews payor denials related to referral, authorizations, level of care and medical necessity. Formulates and submits appeal letters utilizing relevant and effective clinical documentation, evidence based medical necessity criteria, medical policies of the payer, and community and national medical management standards and protocols.
- Coordinates and collaborates with hospital departments (Physicians, Physician Advisors, Clinical Service Lines, Case Management, Health Information Management, Clinical Documentation Improvement, Inpatient and Outpatient Revenue Services, etc) as clinical reviews are performed.
- Collaborates with Physician Advisors to appropriately identify clinical denials that require escalation.
- Documents in appropriate tracking tool for maintenance and distribution of reports as required by Leadership.
- Identifies denial patterns and escalates to management as appropriate with sufficient information for additional follow up, and or root cause resolution.
- Makes recommendations for additions/revisions/deletions to work queues and claim edits to improve efficiency and reduce denials.
- Maintains expertise in clinical validation, reimbursement methodologies, and utilization management specialty areas by participating in professional organizations, seminars and educational programs.
- Attends enterprise hospital meetings under the direction of the Clinical Denials and Appeals Director.
- Performs other duties as assigned.
To qualify you must have a 3-5 years in Clinical RN experience including 2 years of Denial Management or Case Management or related experience and 1-2 years of current experience with reimbursement methodologies.Bachelors Degree Nursing or other Clinical Practice field, Current and valid NYS Registered Nursing License required.
Must have experience with Interqual and or Milliman Disease Management Ideologies.
Strong communication (verbal and written) and interpersonal skills.
Ability to communicate with multiple levels of the organization; Senior Leadership, Physicians, Directors, Clinical and Support Staff.
Demonstrates critical thinking and analytical skills.
Ability to work collaboratively in a team environment.
Demonstrates the ability to handle multiple assignments and carry out work independently with minimal supervision.
Demonstrates responsibility for professional development.
Ability to work a flexible schedule to ensure compliance with deadlines.
Proficient with Microsoft applications and working knowledge of EPIC and other hospital based clinical computer systems..
Required Licenses: Registered Nurse License-NYS
Experience preparing appeals for clinical denials
Certification in Clinical Documentation Improvement
Qualified candidates must be able to effectively communicate with all levels of the organization.
NYU Winthrop provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you’ll feel good about devoting your time and your talents.
NYU Winthrop is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment. All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision. We require applications to be completed online.
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