Clinical Denials Appeals Specialist-RN #62810
This position is responsible for the determination and completion of the clinical appeal that is identified through denials under the Enterprise Patient Financial Services (PFS) Denials Management structure for all payers and Northern Light member organizations. This position is responsible for conducting a comprehensive review of medical denials and clinical documentation to determine if an appeal warranted. In addition, this position is responsible for researching, investigating, processing, and submitting clinical appeals utilizing clinical and regulatory knowledge, including the review of pertinent medical records (physician orders, progress notes, radiology and laboratory results, medication administration, and other supporting medical records). This position requires a thorough knowledge of regulatory and payer requirements and current state/federal level of care criteria, and is held accountable to adhere to policies, procedures, and applicable laws; including metrics related to productivity and quality. This position works under the direction of the Enterprise Payment Variance Manager with a team of Denial Resolution Specialists.