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Clinician, Denials Management

Clinician, Denials Management

Med-MetrixGarden City, NY, US
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Job Purpose

The Clinician reviews appeals against medical records to ensure accuracy and thoroughness.  All appeals produced must accurately reflect what is documented in patients’ medical records.

Duties and Responsibilities

  • Maintain the integrity of information in each appeal produced by the Firm
  • Review a high volume of written appeals to ensure information is medically accurate
  • Use, protect and disclose patients’ protected health information (PHI) only in accordance with the Health Insurance Portability and Accountability Act (HIPAA) standards
  • Research payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment.
  • Make recommendations for workflow revisions to improve efficiency and reduce denials
  • Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate.
  • Identify opportunities for process improvement and actively participate in process improvement initiatives.

Qualifications

  • 4-year degree required
  • Must be a Registered Nurse with clinical experience
  • Experience in medical chart review
  • Hospital nursing experience
  • Strong written communication skills
  • Basic knowledge of MS Excel and the ability to learn proprietary databases
  • Ability to meet on-going deadlines
  • Exceptionally detail-oriented
  • Must work cooperatively and efficiently under pressure
  • Must be goal-oriented

    • Working Conditions

  • Must possess a smart-phone or electronic device capable of downloading applications, for multifactor authentication and security purposes.
  • Physical Demands : While performing the duties of this job, the employee is occasionally required to move around the work area; Sit : perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones, extend arms; kneel; talk and hear.
  • Mental Demands; The employee must be able to follow directions, collaborate with others, and handle stress.
  • Work Environment : The noise level in the work environment is usually minimal.

    • Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, are, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state, or local law.

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    Clinician • Garden City, NY, US