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.