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Clinical Denials and Appeals Analyst

Company: Mercyhealth
Location: Janesville
Posted on: May 2, 2021

Job Description:

Mercyhealth is committed to offering our partners a best place to work and continually evaluates new programs and benefits. We have been recognized locally, regionally and nationally for helping our workers achieve a work/life balance through benefit offerings and innovative programs. Our unique workplace Culture of Excellence is built upon:

  • Employee engagement, empowerment and growth
  • Teamwork toward our common goal providing exceptional health care services with a passion for making lives better
  • An atmosphere of caring and quality that cascades throughout the organization Department/Skill highlights
  • Location: Revenue Cycle - Mercycare Building Janesville, WI
  • Days, 80 hrs/2wksEssential Duties and Responsibilities
  • Familiarity with all aspects of denial management and expertise to analyze if services provided to patients are appropriate as rendered.
  • Communicates to obtain required retro-authorizations for treatment from the insurance payors as needed.
  • Refers denied cases to the assigned Reimbursement Analyst to determine the next steps after the initial review.
  • Demonstrates a strong clinical knowledge base to review developmentally appropriate assessment, plan of care, and the interventions for patient outcome.
  • Utilizes clinical judgment, including applying Interqual screening to evaluate denied claims for potential appeal.
  • Reviews payer denial/rejection rationale and develops responses using evidence-based data to obtain reversals within the timely filing timeframes, per payor contract timeline.
  • Responsible for coordinating, tracking and following up on all RAC audit record requests, audit responses and appeals for the CMS Recovery (RAC) Program.
  • Provides timely response to payer requests, inquiries, and/or complaints.
  • Must be proficient in communicating accurately, clearly, and precisely with both providers and payors.
  • Must stay abreast of treatment guidelines in all specialty areas, including pharmacy.
  • Tracks and inputs pertinent information to the appropriate system(s) and the tracking log.
  • Update the current status of accounts, such as appeal, approval and denial decisions as received by insurance company response.
  • Assumes responsibility for maintaining tracking of all denials and appeals, including copies of all letters for the appeal process, authorization numbers, avoidable days and dollars recovered. Education and Experience
  • Bachelor of Science required / Registered Nurse or Clinical License (I.e. LCSW or Dietician) with a valid State License required.
  • Denial/Appeal/Utilization Management experience preferred.
  • CPT and ICD-10 experience are preferred.
  • Previous experience with InterQual system preferred.
  • Denial Management certification is preferred.
  • Exposure to project management is preferred. SPECIAL PHYSICAL DEMANDS The Special Physical Demands are considered Essential Job Functions of the position with or without reasonable accommodations. While performing the duties of this job, the employee is regularly required to walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; stoop, kneel, crouch, or crawl; and talk or hear. The employee is frequently required to sit and work at a computer for long periods of time. The employee is occasionally required to stand. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus. While performing the duties of this job, the employee must have good manual dexterity to operate keyboard and telephone; repetitive finger/wrist movement associated with use of keyboard; prolonged sitting. The employee must be able to lift or move office related objects

Keywords: Mercyhealth, Janesville , Clinical Denials and Appeals Analyst, Healthcare , Janesville, Wisconsin

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