临床拒付专员
Specialist Clinical Denial
与我们携手开启你的下一段职业旅程。就在这里。
职位类型：
常规
工作时间：
40小时
💙 为什么你会爱上与圣伊丽莎白医疗保健公司一起工作
在圣伊丽莎白医疗保健公司，每个职位都支持我们的使命，为所服务的社区提供全面而富有同情心的护理。超过160年来，圣伊丽莎白医疗保健公司一直是肯塔基州、印第安纳州和俄亥俄州值得信赖的优质护理提供者。我们以改善所服务社区的健康状况为使命，并以卓越、诚信、同情心和团队合作的价值观为指导。我们的员工是我们一切工作的核心。
🌟 支持你的福利
我们投资于你——个人和职业发展。
享受：
- 在入职30天内即可获得具有竞争力的薪资和全面的健康保险。
- 丰厚的带薪休假和灵活的工作时间
- 带有雇主匹配的退休储蓄计划
- 学费报销和职业发展机会
- 健康、心理健康和认可计划
- 通过导师制和内部流动实现职业晋升
职位概述：
审查并解决服务后收到的需要临床输入或解释的拒付情况。
临床拒付专员负责分析、解决、监控并根据需要向拒付主管报告临床拒付情况。临床拒付专员负责处理通过工作队列升级的临床拒付申诉和后续跟进，提供适当的拒付信息提交给相关部门，以确保创建和实施系统、流程和有效性措施（例如补救行动计划），以解决根本原因问题并减少/消除拒付。临床拒付专员应始终遵守所有部门、机构和监管政策和程序。该职位的职责支持圣伊丽莎白医疗保健公司的使命、愿景、价值观和战略。
在与所有患者、家属、访客和其他员工的每一次互动中，展现出尊重、尊严、善良和同理心，无论其文化背景如何。
职位描述：
职位职责：在适当的情况下进行广泛的跟进，完成申诉和向其他相关方进行转介。调查并确保对问题和信息请求作出及时专业的回应，以解决未结账单。持续监控拒付账户工作
查看英文原文
Engage with us for your next career opportunity. Right Here.
Job Type:
RegularScheduled Hours:
40💙 Why You’ll Love Working with St. Elizabeth Healthcare
At St. Elizabeth Healthcare, every role supports our mission to provide comprehensive and compassionate care to the communities we serve. For more than 160 years, St. Elizabeth Healthcare has been a trusted provider of quality care across Kentucky, Indiana, and Ohio. We’re guided by our mission to improve the health of the communities we serve and by our values of excellence, integrity, compassion, and teamwork. Our associates are the heart of everything we do.
🌟 Benefits That Support You
We invest in you — personally and professionally.
Enjoy:
- Competitive pay and comprehensive health coverage within the first 30 days.
- Generous paid time off and flexible work schedules
- Retirement savings with employer match
- Tuition reimbursement and professional development opportunities
- Wellness, mental health, and recognition programs
- Career advancement through mentorship and internal mobility
Job Summary:
Reviews and resolves denials received post-service requiring clinical input or interpretation.
The Clinical Denials Specialist is responsible for analyzing, resolving, monitoring and reporting clinical denials to Denials Unit Manager as appropriate. The Clinical Denial Specialist is responsible for appeals and follow-up on clinical denials escalated through a work queue, providing appropriate denial information to be submitted to departments to ensure systems, processes and measures of effectiveness (e.g. Remediation action plans), are created and implemented to resolve root cause issues and reduce/ eliminate denials. The Clinical Denial Specialist should remain in full compliance with all departmental, institutional and regulatory policies and procedures at all times. The roles and responsibilities of this job support the mission, vision, values and strategies of St. Elizabeth Healthcare.
Demonstrate respect, dignity, kindness and empathy in each encounter with all patients, families, visitors and other employees regardless of cultural background.Job Description:
Job Duties:Performs extensive follow-up, completes appeals and referrals to other stakeholders, when appropriate. Investigates and/or ensures that questions and requests for information are responded to in a timely and professional manner to ensure resolution of outstanding accounts. Performs ongoing monitoring of denials accounts worked, as necessary, to ensure maximization of collection dollars by providing appropriate follow-up and documenting actions taken.Utilizes all appropriate systems to effectively research accounts and complete steps to submit information necessary to process or appeal accounts. Completes follow-up with patients, as necessary, to obtain additional information. Prepares necessary documentation to submit appeals to payers when payment is denied. Complete all necessary outgoing calls and answer incoming calls, as appropriate. Makes revisions or changes to insurance information, as appropriate. Requests the rebilling accounts as necessary. Complete and / or request adjustments to an account, as appropriate, based on adjustment thresholds.Reviews, works and reports (with accuracy) all accounts that have aged more than the specified grace period stipulated in the policies and / or contracts. Documents follow-up on patient accounts appropriately. Tracks and reports violation of prompt pay / adjudication terms by payers. Follows up proactively with payers to provide necessary additional documentation for patient accounts that have been reviewed by payers and awaiting documentation to determine adjudication. Prioritizes work/resources to accomplish objectives and meet deadlines.Maintains compliance with federal, state and local regulations and HIPPA. Maintains the privacy and security of all confidential and protected health information; job duties warrant a “high” level of computer system access (all necessary areas) to patient information ONLY for those job functions as outlined in this job description; uses and discloses only that information which is necessary to perform the function of the job. Interfaces with other key internal and external staff to obtain necessary information to address payment variance, management of issues or requests. Reports issues and trends to appropriate management personnel and works collaboratively to develop solutions.Participates in all educational activities and demonstrates personal responsibility for job performance. Willingness to participate and share expertise on projects, committees and other activities, as deemed appropriate. Meets or exceeds expectations for data quality, customer service, payment variance management turnaround and productivity. Maintains satisfactory attendance record and punctuality record as set forth by St. Elizabeth Healthcare and departmental policies. Consistently demonstrates a positive and professional attitude at work. Performs other duties as assigned.MINIMUM REQUIREMENTSEducation, Credentials, Licenses: If eligible, must have a Compact (multi-state) License in their primary state of residence.Licensed to practice nursing in the state where work is being performedSpecialized Knowledge: Clinical Skills to include the ability to read and interpret medical records.Demonstrates proficiency in Microsoft Office applications and others as required.Demonstrates knowledge and understanding of organizational policies and procedures.Knowledge of insurance regulations, payment guidelines and policies and the ability to communicate and work with payors to get accounts resolved and paid accurately.Extensive knowledge of Medicare and Medicaid regulations.Knowledge of Third Party claim filing, contract reimbursement and other insurance guidelines.Knowledge of UM/Quality conceptsDemonstrate analytical and problem solving skillsKind and Length of Experience: 5 years nursing experienceFLSA Status:
ExemptRight Career. Right Here. If you're looking for the right careers in healthcare, the right place to be is at St. Elizabeth. Join us, and you'll take pride in the level of care we offer our community.
Originally posted on Himalayas