Clinical Denial Coordinator
The Clinical Denial Coordinator is responsible for the identification, mitigation, and prevention of clinical denials. This position is responsible in preparing clinical disputes based upon evidence base criteria documented within the respective medical record. The Clinical Denial Coordinator will conduct analysis on denials and appeal, identifying and presenting both process improvements and revenue protection opportunities. The position will monitor state and federal regulatory agencies to maintain up-to-date knowledge on changing rules and regulations affecting denial prevention and management practice. Additionally, the Clinical Denial Coordinator will stay abreast of payer clinical policies to dispute denials and provide education for prevention of denials, included but not limited to Quality Improvement Organization, Managed Care Clinical Policies, and both National and Local Coverage Determinations
- Using evidence-based criteria, conducts medical necessity review, based upon denial root cause, to prepare the denial argument for all levels of appeals
- Prepare and present case studies with the respective source of denial (Case Management, Physicians, payer, et al)
- Develops, maintains, and manages cases utilizing an internal software appropriate (i.e. denial/appeal summary, outpatient denial summary and audit summary)
- Identifies, monitors and presents monthly denial performance accompanied with case studies and recommendations for process improvements
- Participates in external payer meetings, presenting payer performance related to denials
- Serves as the Subject Matter Expert (SME) for clinical denials documentation and payer clinical guidelines
- Consult with other disciplines and other ancillary departments (i.e. physician, coding, OR, cardiology, pharmacy, purchasing, case management, respiratory therapy, clinical documentation specialists, etc.) as needed to obtain necessary documentation to support clinical appeal and implement prevention
- Responsible for denial reduction through prevention and increase denial recovery through disputes
Required Knowledge and Skills
- Expert in evidence-based criteria, including InterQual, Milliman Care Guidelines
- Understanding and application of payer clinical medical policies
- Requires fundamental knowledge of the revenue cycle process, which includes such things as patient access, utilization review, charge capture, HIM and patient accounting.
- Requires the advanced analytical and critical thinking skills necessary to audit patient care data, associated patient care documentation and identify variances in standards of care.
- Requires knowledge of rules and regulations pertaining to hospital reimbursement.
- Requires familiarity with managed care principles and an understanding of post-acute continuum of care.
- Requires the interpersonal skills necessary to maintain effective working relationships and interact effectively with staff, physicians, review agencies, insurance companies, patients and patients’ families.
- Requires the effective communication skills (both verbal and written) necessary to prepare documentation, write appeal letters and to provide education to staff and physicians regarding the revenue cycle process.
Education and Experience
- Education: Bachelor of Science Degree or a licensed registered nurse with equivalent relevant experience.
- Experience (Type & Length): 5+ years in Quality, Utilization Review, and/or Case Management.
- Certification/Licensure: RN license in good standing, Case Manager Certification