Clinical Denials Coordinator

Summary

Job Summary

The Clinical Denials Coordinator is responsible for managing the initial clinical denials process related to authorizations, notifications, and medical necessity denials for all government and commercial payers for hospital patients.

This role involves reviewing and analyzing initial denials, providing education to providers and case managers, and working closely with the physician advisor(s) and other departments to resolve denials and recover payments.

The Clinical Denials Coordinator serves as a clinical expert on and ensures compliance with medical necessity criteria, inpatient / observation criteria, and Medicare / Medicaid regulations.

Job Responsibilities

• Reviews and analyzes payer denials to determine the cause and develops strategies for resolution.
• Communicates timely with insurance companies, providers, case managers, and other departments to resolve denials and secure payments.
• Maintains detailed documentation of all denials, causes, appeal status, and outcomes.
• Generates and analyzes reports on denial trends, recovery rates, and other relevant metrics to identify opportunities for improvement.
• Provides education and training to case managers, providers, and other healthcare team members on documentation practices and denial prevention strategies.
• Collaborates with clinical and administrative teams to develop and implement process improvements to reduce denial rates.
• Other duties as assigned.

Qualifications

• Associate's degree or higher or Diploma in Nursing required upon hire AND
• Bachelor's degree or higher in Nursing required within 5 years of employment in this position
• A minimum of 3 years' relevant experience required
• RN - Licensed as a Registered Nurse. Eligible to practice nursing in the State of Kentucky required upon hire

Skills and Attributes

• Ability to use critical thinking skills and make sound decisions.
• Ability to work under minimal supervision and be result oriented.
• Ability to work in a stressful environment and take appropriate action.
• Ability to react to frequent changes in duties and volume of work.
• Ability to communicate effectively with multiple disciplines.
• Ability to manage multiple tasks with ease and efficiency.
• Ability to problem solve and develop strategies.
• Ability to implement new processes with minimal disruptions.

Physical Demands

• Standing : Occasionally
• Walking : Occasionally
• Sitting : Frequently
• Lifting 0-25 lbs : Rarely
• Lifting 25-75 lbs : Never
• Lifting over 75 lbs : Never
• Carrying 0-25 lbs : Rarely
• Carrying 25-75 lbs : Never
• Carrying over 75 lbs : Never
• Pushing / Pulling 0-25 lbs : Rarely
• Pushing / Pulling 25-75 lbs : Never
• Pushing / Pulling over 75 lbs : Never
• Climbing : Rarely
• Bending / Stooping : Rarely
• Kneeling : Rarely
• Crouching / Crawling : Rarely
• Reaching : Occasionally
• Talking : Frequently
• Hearing : Occasionally
• Repetitive Foot / Leg Movements : Never
• Repetitive Hand / Arm Movements : Frequently
• Keyboard Data Entry : Frequently
• Running : Never
• Vision : Depth Perception : Frequently
• Vision : Distinguish Color : Frequently
• Vision : Seeing Far : Frequently
• Vision : Seeing Near : Frequently

Owensboro Health Core Commitments

INTEGRITY - We conduct ourselves with a high level of responsibility, reliability and honesty because we take seriously the trust of our patients and coworkers.

RESPECT - We value and accept the unique talents and contributions of every patient, customer and team member in the Owensboro Health community.

TEAMWORK - We build a spirit of connectivity and fellowship by striving together to overcome obstacles, surpass goals, celebrate accomplishments and plan the future.

INNOVATION - We foster original ideas and creative solutions that improve our daily work and promote the mission of Owensboro Health.

SERVICE - We focus on service to patients, customers and team members by anticipating their needs, thoughtfully meeting those needs and continually improving the quality of everything we do.

EXCELLENCE - We reach beyond basic expectations to expand our knowledge and awareness, produce exceptional work and provide outstanding service.