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Clinical Denial Specialist

Clinical Denials | Franciscan Alliance

 

Address  24 Joliet Street
    Dyer, IN 46311

 

Calendar  Part-Time Not Benefit eligible

 

Education High School Diploma/ GED Required

 

Hours  Days

WHAT WE NEED

A persistent person who can find the answers

WHO WE ARE LOOKING FOR

High quality health care is both a calling and a business. And the business side dictates reviewing clinically denied cases, determining if appeals can be made, and providing follow-up. Bottom line: this job is important for back-end operations. Think you’re up for the job?

 

Are you timely and accurate? Are you detail-oriented? Do you love knowing that you’re an integral part of the team? We’ve got a great place to put your skills to work.

WHAT YOU WILL DO
  • Provide feedback to appropriate staff/departments and facilitates performance improvement regarding denials resolution and prevention.
  • Denials management, including reviewing clinically denied cases and prioritize cases to determine if appeal can be made within filing timeframe, as well as pre-certification issues for submitting  appropriate appeals, providing appeal follow-up and completes monthly reporting.
  • Collaborate with case managers in contacting the physician/office staff to obtain further patient information for medical necessity to be used in the appeals process.
  • Collaborate with Division Director on complicated cases to determine if further medical necessity can be established.
  • Perform medical record audits for comparison with third party audits and resolution of patient billing disputes.
  • Perform additional medical record reviews and follow-up as requested.
  • Act as a resource person for inter/intradepartmental personnel as they relate to issues of medical necessity, payor contract interpretation and rules and regulations related to reimbursement.
  • Establish methods of data collection and provide reports.
  • Maintain a database of cases needing appeal, those that are pending, overturned or upheld in order to assure cases are being addressed and within the appropriate timeframe.
  • Attend and participate in house-wide multi-disciplinary committees as pertains to denial management.
  • Participate with corporate administration, corporate case management and AIS for standardization and implementation of corporate-wide computer systems, i.e. Denials Management and Case Management.
  • Coordinate, schedule, and collaborate with AIS in implementing software and hardware  updates and upgrades related to denial management.
  • Define educational needs; develop and facilitate ongoing training for new and existing  computer system users and Case Management department personnel related to denials software.
  • Provide first-line assistance for Case Management system users and coordinate communication with AIS for problem resolution.
WHAT IT TAKES TO SUCCEED
  • Strong analytical skills to collect, analyze, and interpret data.
  • Organizational and prioritizing skills.
  • Strong communication skills, both verbal and written.
  • Knowledge of Denials Management and Case Management computer systems.
  • Maintain current knowledge base for regulations: state, federal, and commercial payors.


 

WHAT WE'RE LOOKING FOR
 

 

3-5 Years Experience

License(s):

Certification(s):


 

EQUAL OPPORTUNITY EMPLOYER

It is the policy of Franciscan Alliance to provide equal employment to its employees and qualified applicants for employment as otherwise required by an applicable local, state or Federal law.

Franciscan Alliance reserves a Right of Conscience objection in the event local, state or Federal ordinances that violate its values and the free exercise of its religious rights.

Franciscan Alliance is committed to equal employment opportunity.


Nearest Major Market: Gary
Nearest Secondary Market: Chicago