This is a hybrid position in Annapolis, MD

Description

Position Summary

The clinical denial appeals specialist is responsible for the identification, mitigation, and prevention of clinical denials. This staff member reviews all initial clinical denials to determine next steps and conducts appeals as appropriate, such as by reviewing medical necessity, responding to authorization concerns, and/or reconciling coverage-related issues. The clinical denial appeals specialist also works to prevent future clinical denials by communicating with clinical and revenue cycle leadership about denial root causes, such as documentation gaps or insufficient charge capture, and helps develop and implement staff education and process changes.

Principal Duties and Responsibilities

• Reviews clinical denials and initiates appeals process, if determined appropriate according to internal guidelines

• Conducts medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals

• Communicates with payer representatives or other stakeholders in appeals process (e.g., mediators, arbitrators, legal counsel)

• Helps present appeals arguments to Administrative Law Judge, if and when appropriate

• Otherwise monitors and follows up on appeals throughout entire process, determining next steps to ensure appeals either result in an overturned denial or have proceeded as far as possible

• Identifies gaps in clinical documentation and works with clinical staff to develop and implement quality improvement and staff education initiatives

• Assesses the quality of charge capture and coding as they relate to clinical denials; assists revenue cycle leadership in improving processes

• Assists case management with concurrent review processes

• Supports billing staff by reviewing high-risk and/or high-dollar accounts before claim submission to prevent clinical denials

• Analyzes initial and fatal denial data to identify trends; shares findings with revenue cycle leadership to drive process improvements

• Supports global denial prevention and mitigation efforts, such as by attending denial task force meetings

Skills

Medical Coding, Clinical Denials, EPIC, EMR

Additional Skills & Qualifications

Certification in at least one of the following preferred: certified healthcare chart auditor, certified professional in utilization review (or utilization management or healthcare management), certified case manager, certified documentation specialist, certified coder, certified professional medical auditor, or similar program

Experience

At least three years of experience required in one of the following areas: clinical, case management, denials, billing

Knowledge, Skills, Abilities

Familiarity with medical coding, billing/reimbursement, and/or audit processes

Ability to interact with payer representatives and understand contract requirements

Familiarity with National Coverage Determinations and Local Coverage Determinations

Proficient in medical terminology and able to interpret patient medical records

Knowledge of medical necessity screening criteria (e.g., Milliman, InterQual)

Proficient in EHR and other systems used by organization (e.g., Epic, Cerner, MEDITECH, Microsoft suite)

Strong time management and prioritization skills

Ability to communicate effectively, especially with clinical staff members

Pay and Benefits

The pay range for this position is $40.00 - $50.00/hr.

• Medical, dental & vision • Critical Illness, Accident, and Hospital • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available • Life Insurance (Voluntary Life & AD&D for the employee and dependents) • Short and long-term disability • Health Spending Account (HSA) • Transportation benefits • Employee Assistance Program • Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a hybrid position in Annapolis,MD.

Application Deadline

This position is anticipated to close on Mar 7, 2025.

About TEKsystems:

We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.