What are the responsibilities and job description for the Outpatient Denial/Appeals Specialist- RN position at Carle?
Outpatient Denial / Appeals Specialist- RN
- Department : Revenue Cycle - CFH_10_19
- Entity : Champaign-Urbana Service Area
- Job Category : Clerical / Admin
- Employment Type : Full - Time
- Job ID : 44345
- Experience Required : 1 - 3 Years
- Education Required : Bachelors Degree
- Shift : Day
- Location : Remote
- Usual Schedule : Monday Friday
- On Call Requirements : no
- Work Location : Working from Home
- Weekend Requirements : no
- Other Posting Information : Registered Professional Nurse (RN) License Illinois upon hire.
- Holiday Requirements : no
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Position Summary :
Serves as an expert resource in outpatient clinical documentation review to establish and manage clinical and prior authorization denial appeals for the Carle enterprise. Represents Carle in clinical meetings and writing appeals on outpatient accounts where medical necessity, level of care or prior authorization is questioned. Performs outpatient post payment reviews where medical necessity is being challenged. Responsible for enterprise wide outpatient clinical review and appeals on Medicare and Medicaid RAC, PERM, CERTs, etc. audits. Assists account representatives with the interpretation of specific payer medical policies. Serves as a liaison with the clinical leadership as well as the payer provider representatives. Creates training materials and process flows. Participates in projects. Involved in system testing and development. Builds and analyzes management summary reports.
Qualifications :
EDUCATIONAL REQUIREMENTS Bachelor's Degree in Nursing CERTIFICATION & LICENSURE REQUIREMENTS Registered Professional Nurse (RN) License Illinois upon hire. EXPERIENCE REQUIREMENTS Three years of experience in health care with focus in reimbursement and / or case management. Proficient in Microsoft Office applications such as Word, Excel, Outlook, Access, Visio, Receivables Management systems and Epic reporting tools (Account Query, Cubes, etc.). SKILLS AND KNOWLEDGE Requires excellent verbal and written communication, negotiation and listening skills. Must be a self-starter who is adept at problem solving and possesses the skills necessary to plan, organize and achieve goals. Performs highly complex and varied tasks requiring independent decision making skills. Ability to multi task and adhere to work plans and time lines. Excellent attention to detail and follow-through. Is innately inquisitive and serves as a role model to others throughout the organization.
Essential Functions :
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information : human.resources@carle.com.
Effective September 20, 2021, the COVID 19 vaccine is required for all new Carle Health team members. Requests for medical or religious exemption will be permitted.
