Nurse Specialist - Clinical Denials and Appeals

Huron helps its clients drive growth, enhance performance and sustain leadership in the markets they serve. We help healthcare organizations build innovation capabilities and accelerate key growth initiatives, enabling organizations to own the future, instead of being disrupted by it. Together, we empower clients to create sustainable growth, optimize internal processes and deliver better consumer outcomes.

Health systems, hospitals and medical clinics are under immense pressure to improve clinical outcomes and reduce the cost of providing patient care. Investing in new partnerships, clinical services and technology is not enough to create meaningful and substantive change. To succeed long-term, healthcare organizations must empower leaders, clinicians, employees, affiliates and communities to build cultures that foster innovation to achieve the best outcomes for patients.

Joining the Huron team means you’ll help our clients evolve and adapt to the rapidly changing healthcare environment and optimize existing business operations, improve clinical outcomes, create a more consumer-centric healthcare experience, and drive physician, patient and employee engagement across the enterprise.

Join our team as the expert you are now and create your future.

The Clinical Denials and Appeals Nurse Specialist (IP & OP) is responsible for reviewing the claims denied and carrying out the appeals process appropriately and in a timely manner. This individual identifies and works denials, responding to the denial reason and resubmitting any information needed to the payor The Clinical Denials and Appeals Specialist should be knowledgeable of U.S. state/federal laws that relate to payor contracts and to the appeals process.  This role requires frequent and effective communication via phone, email, and instant messaging with the various engagement teams. Strong oral and written communication skills, analytical skills, ability to work independently, and be self-motivated are required.

KEY RESPONSIBILITES:

Denials and Appeals Management 

• Work denials and appeals timely, evaluating the denial reason including information from the payor and payor policies, reviewing the clinical documentation, assessing options and completing next steps   

• Submit retro-authorizations in accordance with payor requirements in response to authorization denials

• Conducts medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals.

• Write and submit written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. Appeals are submitted timely and tracked through final outcome.  

• Document all actions taken and follow-up timely as needed related to resolving denials and appeals with third-party payers in a timely manner

• Tracks the status and progress of denials and appeals

• Completes relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms 

• Executes internal and external correspondence accurately, clearly, concisely, and professionally while following organizational regulations 

• Effectively handles all communications, including telephone, electronic, and paper correspondence from payers and departments within the business office 

 
Tracking, Reporting, and Trends  

•  Maintains data on the types of claims denied and root causes of denials 

• Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow-up, and/or root cause resolution 

• Collaborate with management to recommend process changes to address root cause of denials and overall improvement to reduce A/R 

• Prepares, maintains, assists with, and submits reports as required 

Compliance and Continuous Improvement 

• Collaborate with team members to continually improve services, and engage in process and quality improvement activities 

•  Identify system improvement opportunities and contribute to the testing of system modifications 

•  Conducts relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms 

• Complies with state and federal regulations, accreditation/compliance requirements, and Huron’s policies, including those regarding fraud and abuse, confidentiality, and HIPAA 

•  Maintains a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, in order to identify and report billing compliances issues and payer discrepancies 

• Participates in ongoing professional development to enhance job knowledge and performance 

•  Reports all identified compliance risks to appropriate leadership 

  Other duties and responsibilities as assigned. 

QUALIFICATIONS:

Required Qualifications:

• Clinical Appeals Experience: At least 1 year of clinical appeal writing experience.
• Clinical Experience:Minimum of 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred); 2-3 years if ICU experience.
• Education:Associate Degree in Nursing (ADN) or Diploma in Nursing.   
• Licensure: Must be Registered Nurse with an active USRN license. 
• RCM Knowledge:Proficiency in using InterQual or MCG clinical guidelines. Broad Knowledge of U.S. Government Programs and Insurance Regulations 
• Software Knowledge: Proficiency with hospital-based electronic medical records (EMR) such as Epic, Cerner, or Meditech.

Preferred Qualifications:

• Education:Bachelor of Science in Nursing (BSN) preferred 
• Credential/Certification: Case management or clinical appeals or clinical denials certification (ACMA) is preferred.

• Software Knowledge:Proficiency with using computer programs for tracking denials and appeals. Proficiency with Microsoft office suite (Excel, Word, PowerPoint, Outlook, SharePoint) 

• Soft Skills: 

• Ability to pay close attention to details; strong follow-up and follow-through skills 
• Regularly makes complex decisions within the scope of the position, and is comfortable working independently 
• Requires the use of independent judgment, discretion and decision-making abilities 
• Demonstrates teamwork and integrity in all work-related activities 
• Ability to interact with internal and external customers in a professional manner 
• Strong analytical and critical thinking skills.
• Experience in a matrixed environment
• Excellent written and verbal communication skills

The estimated hourly range for this job is $33.65 - $43.27. The range represents a good faith estimate of the range that Huron reasonably expects to pay for this job at the time of the job posting. The actual salary paid to an individual will vary based on multiple factors, including but not limited to specific skills or certifications, years of experience, market changes, and required travel. The job is also eligible to participate in Huron’s benefit plans which include medical, dental and vision coverage and other wellness programs. The salary range information provided is in accordance with applicable state and local laws regarding salary transparency that are currently in effect and may be implemented in the future.

Position Level

Analyst

Country

United States of America