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RN - Clinical Denial Management

Bethany, Illinois
Job Type
1 Aug 2022
The Clinical Denial Management - RN participates in clinical review and development of well-constructed appeal arguments for reconsideration of medical services that may have been denied. Denial of payment may be based on insufficient clinical documentation to support the level of care, utilization review, determination that a treatment is investigational/experimental, and/or that the treatment rendered is not medically necessary.
  • The Clinical Denial Management - RN will review the case, and determine the potential for an appeal on a denied claim.
  • Create quality appeal letters to achieve maximum overturn rate. The appeal letter will be written in an objective narrative form, utilizing appropriate formatting, appropriate English grammar, based on current evidenced based criteria, medical literature if applicable, healthcare statutes, and clinical judgment.
  • Stays abreast of regulatory changes and payer policies.
  • Utilizes evidenced based criteria and other resources to develop sound and well-supported appeal arguments.
  • Performs duties in accordance with the ethical and legal compliance standards as set by Carle Health, and all regulatory agencies, including State and Federal.
  • Maintains strictest confidentiality of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
  • Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services.
  • Review governmental contractors response letter in comparison to the medical records.
  • Researches medical literature and evidence based medical publications to support the level of care provided.
  • Reviews/audits medical necessity denials looking for patterns by services or by the physician.
  • Works with leadership to improve clinical documentation, understand root causes, and to reduce denials.
  • Works collaboratively with health information management coding staff, physicians and financial services to resolve payment denials and clinical documentation issues.
  • Adept at working in a fast paced, collaborative environment with multi-disciplinary teams across the institution.
  • Ensures quality and productivity standards are met or exceeded.
  • Functions effectively within a team and participates and contributes constructively to produce results in a cooperative effort.
  • Ensure workload is completed in an efficient and timely manner.
  • Participates in projects as needed.
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  • Job Reference: 673800708-2
  • Date Posted: 1 August 2022
  • Recruiter: Carle
  • Location: Bethany, Illinois
  • Salary: On Application
  • Sector: Healthcare & Medical
  • Job Type: Permanent