Clinical Denial Appeals Specialist Job Description

Position Summary
The clinical denial appeals specialist is responsible for the identification, mitigation, and prevention of clinical denials. This staff member reviews all initial clinical denials to determine next steps and conducts appeals as appropriate, such as by reviewing medical necessity, responding to authorization concerns, and/or reconciling coverage-related issues. The clinical denial appeals specialist also works to prevent future clinical denials by communicating with clinical and revenue cycle leadership about denial root causes, such as documentation gaps or insufficient charge capture, and helps develop and implement staff education and process changes.

Principal Duties and Responsibilities

• Reviews clinical denials and initiates appeals process, if determined appropriate according to internal guidelines
• Conducts medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals
• Communicates with payer representatives or other stakeholders in appeals process (e.g., mediators, arbitrators, legal counsel)
• Helps present appeals arguments to Administrative Law Judge, if and when appropriate
• Otherwise monitors and follows up on appeals throughout entire process, determining next steps to ensure appeals either result in an overturned denial or have proceeded as far as possible
• Identifies gaps in clinical documentation and works with clinical staff to develop and implement quality improvement and staff education initiatives
• Assesses the quality of charge capture and coding as they relate to clinical denials; assists revenue cycle leadership in improving processes
• Assists case management with concurrent review processes
• Supports billing staff by reviewing high-risk and/or high-dollar accounts before claim submission to prevent clinical denials
• Analyzes initial and fatal denial data to identify trends; shares findings with revenue cycle leadership to drive process improvements
• Supports global denial prevention and mitigation efforts throughout Luminis Health, such as by attending denial task force meetings

The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified and should not be considered a detailed description of all the work requirements that may be inherent to the position.

Position Qualifications

Education

• Registered nurse (RN) licensure required, bachelor’s degree in nursing preferred
• Certification in at least one of the following preferred: certified healthcare chart auditor, certified professional in utilization review (or utilization management or healthcare management), certified case manager, certified documentation specialist, certified coder, certified professional medical auditor, or similar program

Experience

• At least three years of experience required in one of the following areas: clinical, case management, denials, billing
• Previous experience as an acute RN preferred

Knowledge, Skills, Abilities

• Familiarity with medical coding, billing/reimbursement, and/or audit processes
• Ability to interact with payer representatives and understand contract requirements
• Familiarity with National Coverage Determinations and Local Coverage Determinations
• Proficient in medical terminology and able to interpret patient medical records
• Knowledge of medical necessity screening criteria (e.g., Milliman, InterQual)
• Proficient in EHR and other systems used by organization (e.g., Epic, Cerner, MEDITECH, Microsoft suite)
• Strong time management and prioritization skills
• Ability to communicate effectively, especially with clinical staff members