临床拒付专员（远程，远程，美国）
Clinical Denials Specialist (Remote, Remote, US)
职位：临床拒付专员
排班：周一至周五 早上8点 - 下午4:30 美东时间
总体概述：
- 临床拒付专员的目标是成功处理与转诊、授权、通知、不覆盖、医疗必要性及其他相关临床拒付相关的索赔拒付。该专员将审查索赔并建议重新提交索赔、追溯授权、书面申诉，或确定无需采取行动。
- 临床拒付专员将撰写/提交专业书面申诉，包括基于临床记录、保险公司医疗政策和合同条款的论据。申诉将及时提交并跟踪结果和趋势。
所需基础知识、技能和/或能力：
要成功履行此工作，个人必须能够满意地完成每项关键职责。以下要求代表了所需的知识、技能和/或能力。可根据需要进行合理调整，以帮助残疾人履行关键职能。
关键职责和责任：
- 研究指定保险公司的拒付（转诊、授权、通知、医疗必要性和非覆盖服务）
- 独立撰写/提交符合客户和保险公司政策的专业申诉信
- 准备报告供管理层审查并识别趋势
- 审查并理解多个保险公司的使用审查和覆盖指南
- 识别流程改进机会
- 监控拒付和申诉结果及趋势，并向管理层报告发现的情况
- 确保所有拒付管理活动符合联邦、州和保险公司的规定，包括HIPAA要求
其他职责和责任：
- 定期满足管理层分配的特定目标和任务
- 始终保持账户信息的机密性
- 保持对企业和合规计划的了解，并积极参与
- 按管理层指派协助其他项目
- 与州和联邦机构保持良好的工作关系
- 及时解决账户问题
- 保持工作台整洁有序
教育/职业/以往经验建议：
- 商业或医疗相关领域的副学士学位
- 注册护士（RN）资格，具有护理管理、使用审查、事先授权的经验
查看英文原文
Role: Clinical Denial Specialist
Schedule:M - F 8 AM - 4:30 PM EST
GENERAL SUMMARY:
- The goal of the Clinical Denial Specialist is to successfully manage claim denials related to referral, authorizations, notifications, non-coverage, medical necessity, and other clinically related denials, as assigned. The specialist will review claims and make recommendations for claim resubmission, retro authorization, written appeal or if no action is needed.
- The Clinical Denial Specialist will write / submit professionally written appeals including arguments based on the clinical documentation, payer medical policies and contract language. The appeals will be submitted timely and tracked for outcome and trends.
Foundation Knowledge, Skills, and/or Abilities Required:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
Essential Duties and Responsibilities:
- Research assigned payer denials (referral, authorization, notification, medical necessity and non-covered services)
- Independently write / submit professional appeal letters in accordance with client and payer policies
- Prepares reports for management review and identifies trends.
- Reviews and understands utilization review and coverage guidelines for multiple payers
- Identify process improvement opportunities
- Monitor denial and appeal outcomes and trends, and report findings to management.
- Ensure all denial management activities comply with federal, state and payer regulations, including HIPAA rerquirements.
Additional Duties and Responsibilities:
- Meet specified goals and objectives as assigned by management on a regular basis.
- Maintain confidentiality of account information at all times.
- Maintain awareness of and actively participate in the Corporate Compliance Program.
- Assist with other projects as assigned by management
- Maintain good working relationships with state and Federal agencies.
- Resolve accounts in a timely manner.
- Maintain a neat and orderly work station
Educational/Vocational/Previous Experience Recommendations:
- Associates Degree in a business or healthcare related field.
- Registered Nurse (RN) Certification with experience in care management, utilization review, prior authorization and appeals.
- Electronic Health Record Experience with various platforms (Epic, Cerner, Meditech)
- Knowledge of all insurance payers preferred.
- Proficient PC knowledge and the ability to type 30-40 wpm.
- Professional written and verbal communication skills.
- Capacity to prioritize multiple tasks in a busy work environment.
- Organization and time management skills.
- Capability to present oneself in a courteous and professional manner at all times.
- Ability to stay on task with little or no supervision.
Working Conditions:
- Must be able to sit for extended periods of time.
Benefits including but not limited to: Medical, Vision, Dental, 401K, Paid Time Off.
We are an Equal Opportunity Employer. All qualified applicants are considered for employment without regard to race, color, age, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by federal, state or local law.
Not Accepting Referrals
Originally posted on Himalayas