Clinical Denials and Appeals Analyst
Posted on: May 2, 2021
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,
- 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
- 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
- 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
- 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
- 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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