Denials Specialist

Category:

RN Professional

City:

Jackson

State:

Tennessee

Shift:

8 - Day (United States of America)

Job Description Summary:

Under the general direction of the Director of Medical Oncology and the Business Manager, the denials specialist is responsible for timely and accurate resolution of denied insurance claims. The denials specialist will research, appeal, and track all departmental denials. Responsibility also includes the implementation of processes to prevent future denials.

ESSENTIAL JOB FUNCTIONS:

• Partners with Revenue Cycle team and Business Office team to support resolution of retrospective denials.

• Responsible for understanding each payer’s medical necessity criteria. Performs written and verbal appeals for denials.

• Collaborates with physicians, nursing, coding, billing and others in appeals process.

• Tracks and trends denials. Identifies frequent root causes of denials and develops corrective action plan with appropriate departments.

• Tracks denial recovery data and generates monthly/quarterly/annual reports to show financial impact.

• Educates staff and physicians regarding processes to proactively reduce the risk of denials.

• Insures successful orientation and continuous education and development of clinical and clerical staff regarding denials prevention.

• Serves as an educational resource to staff.

• Makes management of aware of any issues or changes with payers.

• Assists with chart audits as necessary.

• Performs other duties as assigned or required.

JOB SPECIFICATIONS:

EDUCATION:

• Completion of a diploma, associate or baccalaureate degree in nursing

           

LICENSURE, REGISTRATION, CERTIFICATION:

• Current licensure as a Registered Nurse as approved by the Tennessee Board of Nursing for practice in the State of Tennessee

EXPERIENCE:

• Competency in reading medical records.  Minimum of 2 years hospital experience as a RN is required.  Prefer experience with utilization review process involved in working with health plans

KNOWLEDGE, SKILLS AND ABILITIES:

• Skill and proficiency in the principles, concepts and techniques of the nursing profession as normally acquired through the completion of a diploma, associate, or baccalaureate degree in nursing

• Excellent verbal and written communication skills

• Ability to organize and prioritize workload in order to meet deadlines

• Must have strong knowledge of computer software applications in word processing, spreadsheets and presentations, including MS Word, Excel and PowerPoint

INTERPERSONAL REQUIREMENTS:

• Must have high level of interpersonal skills.  Position continually requires demonstrated professionalism, tact and diplomacy

• Must be able to work and communicate effectively with all areas of hospital personnel including ancillary departments, Nursing, Billing, Medical Records and Physicians

• Contributes to a positive work environment and the overall team effort of the department

NONDISCRIMINATION NOTICE STATEMENT

We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, ethnicity, disability, religion, national origin, gender, gender identity, gender expression, marital status, sexual orientation, age, protected veteran status, or any other characteristic protected by law.