Senior Specialist, Clinical Denials & Appeals (RN)

NYU Langone Health is a world-class, patient-centered, integrated academic medical center, known for its excellence in clinical care, research, and education.

It comprises more than 200 locations throughout the New York area, including five inpatient locations , a children's hospital , three emergency rooms and a level 1 trauma center.

Also part of NYU Langone Health is the Laura and Isaac Perlmutter Cancer Center , a National Cancer Institute designated comprehensive cancer center, and NYU Grossman School of Medicine , which since 1841 has trained thousands of physicians and scientists who have helped to shape the course of medical history.

At NYU Langone Health, equity, diversity, and inclusion are fundamental values. We strive to be a place where our exceptionally talented faculty, staff, and students of all identities can thrive.

We embrace diversity, inclusion, and individual skills, ideas, and knowledge. For more information, go to nyulangone.org , a nd interact with us on LinkedIn , Glassdoor , Indeed , Facebook , Twitter , YouTube and Instagram .

Position Summary :

We have an exciting opportunity to join our team as a Senior Specialist, Clinical Denials & Appeals.

In this role, the successful candidate assists the Director in the overall coordination of daily workflow to the Appeal Writers for all NYU Langone campuses.

Will analyze denials that have been concurrently certified and overturned on P2P while identifying and presenting both Process Improvement and Revenue Protection opportunities.

Will provide training and education to new appeal writers as the scope of the Internal Appeals team expands to the other campuses.

Will review ongoing processes and collaborate with other senior specialists, director, and interdisciplinary groups to help develop strategies to improve workflow, team education, and efficiencies.

Job Responsibilities :

• Develops and implements Standards of Practice for the Clinical Denials and Appeals Specialists as it relates to formulating and submitting responses to Clinical Denials from commercial payors, Managed Care and Third Party Review Organizations.
• Manages and prioritizes timely review, investigation and response to Clinical Denials and the required actions for appeals within contractual timeframes.
• Conducts ongoing evaluation of Clinical Denials and Appeals Specialists as it relates to analysis of adverse determinants, knowledge and application of coding regulations, timely review and response to payor denials, and maintenance of department metrics.
• Coordinates and collaborates with Content Experts across the enterprise (Physicians, Physician Advisors, Clinical Service Lines, Case Management, Health Information Management and Clinical Documentation Improvement, Inpatient and Outpatient Revenue Services, etc) as needed to obtain necessary documentation and information to support Clinical Appeals and implement prevention strategy.
• Assists with the development, maintenance and management of cases utilizing an internal tracking tool for the distribution of reports as needed by Leadership.
• Analyzes and presents monthly denial performance data accompanied with case studies and recommendations for Process Improvements at Enterprise - wide Forums.
• Maintains expertise in clinical validation, coding guidelines and reimbursement methodologies, by participating in professional organizations, seminars and educational programs.
• Executes second level and external reviews and provide team members feedback with ongoing education
• Provides orientation, training, and education to Clinical Denials and Appeals Specialists.
• Provides orientation, training and education to staff and participles in hospital-wide forums as needed.

Minimum Qualifications :

To qualify you must have a Bachelors degree in Nursing.

Active NYS RN license.

3-5 years Clinical Denials and Appeals experience.

Minimum of 5 years of well-rounded clinical nursing experience in an acute care setting.

Minimum of 3 years of case management experience

Demonstrates and maintains ongoing responsibility for professional development.

Ability and willingness to work a flexible schedule to ensure compliance with deadlines.

Strong communication (verbal and written) and interpersonal skills.

Ability to communicate with multiple levels of the organization; Senior Leadership, Physicians, Directors, Clinical and Support Staff.

Demonstrates critical thinking and analytical skills.

Ability to work collaboratively in a team environment.

Demonstrates the ability to handle multiple assignments and carry out work independently with minimal supervision.

Proficient with Microsoft applications and working knowledge of hospital based clinical computer systems..

Required Licenses : Registered Nurse License-NYS

Preferred Qualifications :

Experience preparing appeals for Clinical Denials

Masters degree in Nursing or other health related field (or in process).

3 years of experience in leadership or managerial role.

EPIC experience

Familiarization with MCG Guidelines

Familiarization with Interqual Criteria

Qualified candidates must be able to effectively communicate with all levels of the organization.

NYU Langone Health provides its staff with far more than just a place to work. Rather, we are an institution you can be proud of, an institution where you'll feel good about devoting your time and your talents.

NYU Langone Health is an equal opportunity and affirmative action employer committed to diversity and inclusion in all aspects of recruiting and employment.

All qualified individuals are encouraged to apply and will receive consideration without regard to race, color, gender, gender identity or expression, sex, sexual orientation, transgender status, gender dysphoria, national origin, age, religion, disability, military and veteran status, marital or parental status, citizenship status, genetic information or any other factor which cannot lawfully be used as a basis for an employment decision.

We require applications to be completed online.

If you wish to view NYU Langone Health's EEO policies, please click here . Please click here to view the Federal "EEO is the law" poster or visit https : / / www.

dol.gov / ofccp / regs / compliance / posters / ofccpost.htm for more information.

NYU Langone Health provides a salary range to comply with the New York state Law on Salary Transparency in Job Advertisements.

The salary range for the role is $97,589.95 - $135,000.00 Annually. Actual salaries depend on a variety of factors, including experience, specialty, education, and hospital need.

The salary range or contractual rate listed does not include bonuses / incentive, differential pay or other forms of compensation or benefits.

To view the Pay Transparency Notice, please click here

Required Skills

Required Experience