Registered Nurse Denials Management Specialist

All the benefits and perks you need for you and your family:

• Benefits from Day One
• Paid Days Off from Day One
• Student Loan Repayment Program
• Career Development
• Whole Person Wellbeing Resources

Our promise to you:

Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Schedule: Full Time;

Shift: Monday-Friday

Location: Virtual

The role you’ll contribute:

The Denials Management Clinical Specialist RN is responsible for reviewing and appealing denials for all clinical services across the AH system. Various types of denial review, appeal, and further action include but are not limited to charge audit/charge capture denials, charge correction, clinical validation, services deemed experimental, services denied according to various payer policies, inpatient level of care, NICU level of care, readmissions, etc. The ability to craft appeals demonstrating stellar grammatical skills and sentence structure in a concise and compelling manner, clearly demonstrating how the clinical scenario met the specific requirements against which the denial was generated by the payer, is a continuous expectation. This role will actively participate in meetings via Microsoft Teams on video and collaborate with departmental processes. The Clinical Denial Management Specialist will serve as a resource for all clinical questions and guidance on working clinical denials and will communicate with other departments to ensure accurate and timely claim adjudication as well as adhering to the AHS Compliance Plan and to all rules and regulations of applicable locate, state, and federal agencies/accrediting entities.

The value you’ll bring to the team:

• Reviewing and appealing denials for all clinical services across the AH system.
• Researching various sources of information to determine appropriateness of appeal vs. other action which includes conducting account history research, navigating patient encounters, reviewing payer website and other resources as applicable, researching charge and payment histories, and any other application necessary to formulate a cohesive and complete clinical appeal or decision regarding other action.
• Various types of denial review, appeal, further action which include but are not limited to: charge audit/charge capture denials, charge correction, clinical validation, services deemed experimental, services denied according to various payer policies, inpatient level of care, NICU level of care, readmissions, etc.
• Making appropriate charge corrections for rebilling
• Collaborates with pre-access, patient financial services, revenue integrity, clinical documentation Improvement, clinical department staff, Coding, physician offices, and utilization review staff to obtain further patient information to be used in the appeals process as necessary.

The expertise and experiences you’ll need to succeed:

Minimum qualifications:

• Bachelor’s degree in field such as nursing, management, business
• Minimum of three (3) years’ experience as Registered Nurse (RN) in an acute clinical setting, preferably including ICU and ED experience
• Current and valid RN license

Preferred qualifications:

• Advanced degree in any field of study
• Experience in charge capture, denial management, utilization review, case management, clinical documentation improvement, revenue integrity, or related field