[Hiring] Clinical Denials & Appeals Specialist @Northwell Career Site
Role Description
This role involves reviewing and responding to Corporate Compliance Audits and serving as a resource for the Health System.
• Reviews denial trends and identifies coding issues and knowledge gaps.
• Serves as liaison between the patient and facility/physician and the third party payer.
• Prepares and defends level of care and medical necessity for assigned case.
• Collaborates with physician advisor, payor representative, and site case managers to facilitate appropriate level of care decisions and billing status.
• Ensures compliance with the Utilization Review standard and regulations.
• Performs concurrent and retrospective utilization management using evidenced-based medical necessity criteria.
• Conducts clinical reviews and formulates appeal letters to support appropriateness of admission and continued length of stay.
• Ensures compliance with current state, federal, and third-party payer regulations.
• Ensures clinical reviews and appeals are up to date and accurately reflect patient’s severity of illness and intensity of services provided.
• Performs related duties as required.
Qualifications
• Graduate from an accredited School of Nursing.
• Bachelor's Degree in Nursing, preferred.
• Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date.
• Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
• Inpatient clinical experience; 4+ years preferred.
• Prior Acute Case Management and/or Utilization Review experience, preferred.
• Must have experience with Milliman Care Guidelines and/or InterQual.
Requirements
• Fully remote role
• Days: Sunday - Thursday
• Hours: 8:00am - 4:00pm
Benefits
• The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.
• When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).
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This role involves reviewing and responding to Corporate Compliance Audits and serving as a resource for the Health System.
• Reviews denial trends and identifies coding issues and knowledge gaps.
• Serves as liaison between the patient and facility/physician and the third party payer.
• Prepares and defends level of care and medical necessity for assigned case.
• Collaborates with physician advisor, payor representative, and site case managers to facilitate appropriate level of care decisions and billing status.
• Ensures compliance with the Utilization Review standard and regulations.
• Performs concurrent and retrospective utilization management using evidenced-based medical necessity criteria.
• Conducts clinical reviews and formulates appeal letters to support appropriateness of admission and continued length of stay.
• Ensures compliance with current state, federal, and third-party payer regulations.
• Ensures clinical reviews and appeals are up to date and accurately reflect patient’s severity of illness and intensity of services provided.
• Performs related duties as required.
Qualifications
• Graduate from an accredited School of Nursing.
• Bachelor's Degree in Nursing, preferred.
• Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date.
• Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
• Inpatient clinical experience; 4+ years preferred.
• Prior Acute Case Management and/or Utilization Review experience, preferred.
• Must have experience with Milliman Care Guidelines and/or InterQual.
Requirements
• Fully remote role
• Days: Sunday - Thursday
• Hours: 8:00am - 4:00pm
Benefits
• The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.
• When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).
Apply tot his job
Apply To this Job