Clinical Denials Appeals Specialist-RN

Job Number 62810
Posted 9/13/2019
Account Northern Light Health Home Office
Department Patient Financial Services
Location |ME| Northern Light Health Home Office-43 Whiting Hill Rd., ME 04412
Schedule Regular Full-time
Shift Day
Hours 0800-1700
Job Details

Job Summary

This position is responsible for the determination and completion of the clinical appeal that is identified through denials under the Enterprise Patient Financial Services (PFS) Denials Management structure for all payers and Northern Light member organizations. This position is responsible for conducting a comprehensive review of medical denials and clinical documentation to determine if an appeal warranted. In addition, this position is responsible for researching, investigating, processing, and submitting clinical appeals utilizing clinical and regulatory knowledge, including the review of pertinent medical records (physician orders, progress notes, radiology and laboratory results, medication administration, and other supporting medical records). This position requires a thorough knowledge of regulatory and payer requirements and current state/federal level of care criteria, and isheld accountable to adhere to policies, procedures, and applicable laws; including metrics related to productivity and quality. This position works under the direction of the Enterprise Payment Variance Manager with a team of Denial Resolution Specialists.

Education andExperience

·Current license required.

·5 years of working experience in healthcare revenue cycle business, nursing or equivalent related experience required.

·2+years of experience in case management, discharge planning, and/or utilization review is preferred.

Required MinimumKnowledge, Skills and Abilities

·Detailed knowledge of payer regulations, principles of accounting, reimbursement concepts and automated account receivable systems.

·Knowledge of medical terminology, Current Procedural Terminology (CPT), and International Classification ofDisease (ICD).

·Must possess strong analytical and problem-solving skills.

·Working knowledge of medical necessity criteria.

·Excellent professional communication skills; both oral and written.

·Ability to demonstrate accuracy and thoroughness; identify ways to improve and promote high quality.

·Proficient with Microsoft business applications.

·Experience with Northern Light Health patient accounting software is preferred.

·Demonstrated dependability to this role and the organization.

·Strong ability to work both independently and collaboratively.

Essential Functions


·Actively participate in team huddles and meetings by way of sharing knowledge, requesting information, and recommending process improvements.

·Effectively collaborate with providers and clinical staff to assist in the process of information gathering to develop an effective appeal.


·Escalate and resolve clinical appeal disputes with payers; serve as a liaison between member organization and payer by working collaboratively.

·Work closely by way of problem solving with other revenue cycle departments to address clinical appeal disputes orchanges that directly impact the accounts receivable.

·Prepare feedback to Revenue Cycle resources including coding, CDI, practice managers, revenue integrity/CDM Managers on the results of the clinical appeal submissions.


·Prepare convincing appeal arguments,using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory arguments and payer policies.

·Conduct timely investigations of clinical denials, including the research and formulation of appeals for various government and commercial payers.

·Apply current clinical knowledge to medical data regarding diagnosis treatment, prognosis, and impairment to compose compelling appeal letters justifying the level of care provided to patients

·Adhere to departmental procedures and performance standards.

·Address issues that require immediate attention; make recommended solutions.


·Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied and whether an appeal is required.

·Utilizer-existing criteria and other resources and clinical evidence to develop sound and well supported appeal arguments, when an appeal is warranted.

·Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.

·Provide key and relevant information for the fiscal month summary of changes in the accounts receivable.


·Maintains knowledge of current state/federal laws that relate to contracts and the appeals process.

·Maintain the knowledge of payer policies; attend local, regional, or national conferences/seminars to remain current.


·Demonstrate departmental desire to provide community benefits by way of charitable events or contribution outside the four walls of the department.

Safety Requirements

·Assist in maintaining a work environment free from recognized hazards that create a risk or injury to employees, patients, or visitors

·All accidents and incidents are reported by employees within 24 hours and supervisor to submit properly investigated report timely

·Ergonomic evaluations are completed as needed

·When appropriate, assist and support with the return of all workers with work related injuries and illness to gainful employment

Physical Demands

·Sedentary:Exerting up to 10 lbs.occasionally, sitting most of the time, and only brief periods of standing and walking.

·Requires the ability to travel to member organizations as needed

Note: the duties listed above reflect the majority of the essential duties of this job and does not, nor is it intended to, reflect all essential duties that may be required for an incumbent in this job to perform.

Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.

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