Denial Mgmt Clinical Analyst – Professional

Denial Mgmt Clinical Analyst – Professional

Requirements

• Bachelor’s degree in Nursing
• Registered nurse with valid Ohio license
• 3 – 5 years of job related experience
• Knowledge of third party payer contracts
• Knowledge of clinical practice guidelines
• Personal computer skills required, including use of Microsoft Word, Microsoft Excel, EPIC
• Experience in gathering information, monitoring indicators, and feedback mechanisms
• Strong interpersonal skills
• Ability to research, evaluate information, analyze problems and make appropriate recommendations
• Demonstrated conflict resolution skills
• Assertive communication skills

Responsibilities

• Responds positively to, and adapts to, department and organizational changes
• Knowledgeable of relevant state and federal laws/statutes/regulations pertaining to utilization, quality or reimbursement, and how those impact care at the point of service
• Knowledge of clinical practice guidelines and appropriateness of clinical interventions
• Performs medical record review, abstracting, aggregating, analyzing, interpreting and reporting complex clinical data obtained from the record
• Compares data from the inpatient records to established criteria, determining legitimacy of admission, treatment, status, and length of stay
• Prepares organized, clear, concise, accurate and informative written correspondence to the payer, analyzing the specified issues and clearly outlining the organization’s expectations
• Accurately tracks in denials system actions taken to resolve denials and outcomes of those actions
• Identifies clinical documentation, quality or legal issues and communicates those issues to the department leadership
• Communicates clearly and collaborates effectively with internal and external customers
• Utilizes facts, negotiation skills, persuasive abilities, adaptability and flexibility in resolving issues with internal and external customers
• Has knowledge of 3rd party payer contracts, their terms, and how these impact point of service
• Utilizes critical thinking skills in the identification of denials, analysis of denials, resolution of denials, and prevention of denials
• Performs calculations to determine expected reimbursement, identify contractual adjustments, and evaluate the application of contract terms
• Manage projects assigned by department leadership
• Defines opportunities to improve denials management processes and department performance

Preferred Qualifications

• Knowledge of hospital reimbursement, third party billing, government rules and regulations
• Knowledge of InterQual and MCG
• Performance improvement
• Medicare rules and regulations