Specialist-Denial I

Reviews clinical information and supporting documentation for outpatient or Part B services to determine appeal action. Reports to the manager of the Denial Mitigation Department. Performs other duties as assigned.

Responsibilities

• Reviews, assesses, and evaluates all communications received in order to optimize reimbursement.
• Evaluates clinical information and supportive documentation prior to initial appeal action in order to optimize reimbursement and utilization of resources.
• Prepares response to appeal/request for information based on supporting clinical information in order to enhance reimbursement and maximize customer satisfaction.
• Compiles, analyzes, and distributes necessary clinical and financial information and presents reports to other healthcare providers in order to improve performances, and increase awareness of resources consumed related to reimbursement.
• Completes assigned goals.

Education

Minimum: Ability to type and/or key accurately and have strong organizational skills.

Experience

Preferred: 3 years clinical experience and at least or 3 years payer experience.

Minimum: 2-5 years clinical experience in a clinical care setting.

Licensure, Registration, Certification

Preferred: RHIT; LPN;RN

Special Skills

Minimum: Excellent communication skills. Advanced computer literacy skills with the ability to type and key accurately.

Training

Minimum: Requires critical thinking and judgement and must demostrates the ability to appropriately use standard criteria established by payers.