Health System Specialist jobs in Tulsa, OK

Job Summary: The Clinical Denials Specialist (RN) analyzes clinical denials, drafts detailed appeal letters, and communicates trends for clinical denials. This role reviews audit finding letters from third party payers to obtain a clear understanding of audited diagnosis codes and underlying clinical/coding rationale.

Minimum Education: Has completed the basic professional curricula of a school of nursing as approved and verified by a state board of nursing, and holds or is entitled to hold a diploma or degree therefrom.

Licensure, Registration and/or Certification: Valid multi-state or State of Oklahoma Registered Nurse License. CCDS (Certified Clinical Documentation Specialist).

Work Experience: Minimum 5 years of related experience.

Knowledge, Skills and Abilities: Intermediate understanding of Explanation of Benefits form (EOB), Managed Care Contracts, Contract Language and Federal and State Requirements. Working knowledge of hospital billing form requirements (UB-04). Working knowledge of Interventional Classification of Diseases, Tenth Revision (ICD-10), Healthcare Common Procedure Coding System (HCPCS) coding, and medical terminology. Ability to demonstrate critical thinking, problem-solving and deductive reasoning skills. Superior interpersonal and communication skills, both written and verbal that present clear and concise information to a diverse audience. Ability to integrate the analysis of data to discover facts or develop knowledge, concepts, or interpretations. Ability to be detail oriented in the examination of clinical and numerical data.

Essential Functions and Responsibilities: Performs clinical reviews of the medical record in response to audits from third party payers. Evaluates and assesses the medical record for specificity of illness, accuracy of clinical documentation, and documentation to support code assignment. Reviews audit finding letters from third party payers to obtain a clear understanding of audited diagnosis codes and underlying payer clinical/coding rationale. Analyzes medical records to obtain supporting clinical documentation for billed diagnosis codes. Communicates findings to third party payers in detailed letters to prevent downgrade payment recoveries. Makes decisions to update DRG's (Diagnostic Related Group), remove, or add to billed diagnosis codes based on clinical reviews. Communicates with third party payers, or providers to obtain additional clinical details or rationales. Identifies audit trends, provides feedback to management, and operates as a subject matter expert. Adheres to all applicable laws, regulations. and guidelines.

Decision Making: Independent judgement in making decisions involving non-routine problems under general supervision.

Working Relationship: Coordinates activities of others (does not supervise). Leads others in same work performed (does not supervise). Works directly with patients and/or customers. Works with internal and/or external customers via telephone or face to face interaction. Works with other healthcare professionals and staff. Works frequently with individuals at Director level or above.

Special Job Dimensions: None.

Supplemental Information: This document generally describes the essential functions of the job, and the physical demands required to perform the job. This compilation of essential functions and physical demands is not all inclusive nor does it prohibit the assignment of additional duties.

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