AdventHealth Corporate

All the benefits and perks you need for you and your family:

• Benefits from Day One
• Career Development
• Whole Person Wellbeing Resources
• Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full-time

Shift: Monday-Friday

Job Location: Virtual

The role you’ll contribute:

Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all. This position is responsible for investigating and appealing clinical related denials from payers.  The position will work post-remit clinical denials, both Inpatient and Outpatient. The ability to effectively communicate and knowledge of appeal guidelines will be vital to the role. The Clinical Denial Management Specialist will serve as a resource for all clinical questions and guidance on working clinical denials and will communicate with other departments to ensure accurate and timely claim adjudication. The Clinical Denial Management Specialist will adhere to the AHS Compliance Plan and to all rules and regulations of all applicable local, state and federal agencies and accrediting bodies.

The value you’ll bring to the team:

• Reviewing and appealing denials for all clinical services across the AH system.
• Researching various sources of information to determine appropriateness of appeal vs. other action which includes conducting account history research, navigating patient encounters, reviewing payer website and other resources as applicable, researching charge and payment histories, and any other application necessary to formulate a cohesive and complete clinical appeal or decision regarding other action.
• Various types of denial review, appeal, further action which include but are not limited to: charge audit/charge capture denials, charge correction, clinical validation, services deemed experimental, services denied according to various payer policies, inpatient level of care, NICU level of care, readmissions, etc.
• Making appropriate charge corrections for rebilling
• Collaborates with pre-access, patient financial services, revenue integrity, clinical documentation Improvement, clinical department staff, Coding, physician offices, and utilization review staff to obtain further patient information to be used in the appeals process as necessary.
• Provide feedback on identified clinical denial trends and recommended remediation as required or requested by supervisors.
• Recommends or educates others on proper documentation, payer processes, and policies in a denial prevention strategic focus as requested.
• Able to defend and appeal denied claims via both written and verbal communication in clear and concise arguments/rationale in clinical terms/language.
• Capable of researching underlying root cause, collecting required information or documents, and adjusting the account as necessary from all related internal and external information sources.
• Able to work in multiple IT solutions at one time to ascertain the complete clinical and financial information required to formulate comprehensive written appeals.
• Escalates any discrepancies and issues encountered to supervisors in a timely manner. Keeps up to date on department and organization policies as well as payer and all regulatory and compliance rules and regulations.
• Participates in any meetings, phone conferences or webinars as needed to either appeal cases or expand knowledge regarding the appeal process, changing rules and regulations, and understanding payer contract language.
• Strives towards meeting and exceeding productivity and quality expectations to align performance with assigned roles and responsibilities. Escalates concerns or difficulties in meeting performance expectations in a timely manner.
• Performs other duties as assigned by management.

The expertise and experiences you’ll need to succeed:

Minimum qualifications:

• Bachelor’s degree in field such as nursing, management, business
• Minimum of three (3) years’ experience as Registered Nurse (RN) in an acute clinical setting, preferably including ICU and ED experience

KNOWLEDGE AND SKILLS REQUIRED:

• Extensive understanding of CPT, HCPCS, ICD, UB-04, LCD/NCD, revenue Codes, modifiers, billing practices, regulations, and guidelines for government and commercial payers
• Understanding of charge capture, revenue integrity concepts, and defense of appropriately assigned charges on appeal
• Ability to defend the clinical validation of assigned diagnoses
• Experience with utilization review and understanding of assignment of Inpatient vs. Observation according to appropriate application of MCG and InterQual
• Ability to quickly navigate the electronic medical record, understand services performed, and correlate those services to charges on the bill
• Strong critical thinking and problem-solving skills with ability to multi-task or reprioritize quickly in a high productivity, fast paced environment
• Ability and willingness to continuously learn new concepts and skills required to navigate ever-changing reimbursement / denials landscape

Preferred qualifications:

• Certification in Case Management (ACMA/CCM)
• Certification Clinical Documentation (CDIP)
• Advanced degree in any field of study
• Experience in denial management, utilization review, case management, clinical documentation improvement, revenue integrity, or related field