Denial Prevention Specialist

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

• Benefits from Day One: Medical, Dental, Vision Insurance, Life Insurance, Disability Insurance

• Paid Time Off from Day One

• 403-B Retirement Plan

• 4 Weeks 100% Paid Parental Leave

• Career Development

• Whole Person Well-being Resources

• Mental Health Resources and Support

• Pet Benefits

Schedule: Full time Shift: Day (United States of America) Address: 900 WINDERLEY PL City: MAITLAND State: Florida Postal Code: 32751 Job Description: Provides education and updates on processes to team members. Interacts with physicians, physician office personnel, and case management departments to complete authorization processes and requirements for Local Coverage Determinations/National Coverage Determinations or incorrect planned status for pending procedures. Ensures requested clinical documentation and physician office notes are followed-up and scanned to the electronic medical record. Adheres to HIPAA regulations and keeps up-to-date with industry standards, medical coverage policies, and reviews materials to enhance knowledge. Maintains yearly InterQual knowledge base by attending update webinars. Evaluates patient status within 24 hours of requests from the authorization team or payer representatives. Reviews clinical information, regulatory guidelines, payer rules, and contracts to make status determinations. Facilitates peer-to-peer reviews for high acuity/high reimbursement risk procedures denied for authorization. Delegates tasks to support staff, ensuring they understand the importance and rationale behind each responsibility. Updates electronic medical records for accurate billing and to enhance clean claim rate percentage. Participates in team collaboration and meetings to streamline workflows and expand the program for potential reimbursement impact. Works closely with Patient Financial Services, Pre-Access, and Health Information Management teams to exchange information and establish a cycle of process improvement. Works proactively to avoid denials and provides additional information and clarification to authorization team members. Performs other duties as assigned Knowledge, Skills, and Abilities:

• Proficiency in basic computer skills and programs (i.e., Word, Outlook, Excel, etc.) [Required]
• Familiarity in EMR navigation, demonstrating mastery of data extrapolation [Required]
• Working knowledge of InterQual criteria and its application [Required]
• Ability to find the required CMS LCD/NCD and comprehend the clinical requirements for the given procedure and regulatory implications. [Required]
• Investigative review knowledge of the medical record [Required]
• Proficiency with using multiple computer applications interchangeably including but not limited to: Athena, Experian, SharePoint, and the like. [Required]
• Ability to access payer websites to look for medical coverage policies and apply the criteria to the specific procedure. [Required]
• Ability to communicate with all parties (i.e., staff, team members, payers, etc.) in a helpful and courteous manner while extending exemplary professionalism. [Required]
• Anticipates and responds to inquiries and needs in an assertive, yet courteous manner. [Required]
• Demonstrates positive interdepartmental communication and cooperation. Communicates professionally with an acceptable use of English (speaking, reading, and writing) [Required]
• Ability to articulate in both written and verbal communication to formulate clear and concise rationale in clinical terms/language [Required]
• Ability to follow oral and written directions [Required]
• Critical thinking and problem-solving skills regarding the clinical review and criteria specific to a procedure or hospital stay as indicated by the specific payer [Required]
• Ability to research procedure of all types, clinical areas, medical specialties, and practice arenas to determine the required documentation to substantiate authorization providing a positive impact on reimbursement [Required]
• Ability to multi-task and work in a potentially stressful, fast-paced environment with tight timelines for work completion [Required]
• Ability to respect the autonomy of the remote work environment and work with people of diverse backgrounds [Required]
• Ability to be self-directed when required, and work independently with limited supervision [Required]
• Excellent customer service skills and communication etiquette [Required]
• Basic understanding of an explanation of benefits (EOB) [Required]
• Basic knowledge of CPT, ICD-10, and HCPCS coding standards [Required]
• Strong organizational skills [Required]
• Strong keyboard and 10 key skills [Required]
• Interpersonal skills to promote teamwork throughout the Denials Prevention team [Required]
• Ability to prioritize and problem-solve [Required]
• Self-motivated and able to work with multiple and multi-functional teams [Required]
• Work within very tight time frames [Required]
• Experience with Medicare/commercial utilization review [Preferred]
• Experience obtaining commercial authorizations [Preferred]
• Working knowledge of CMS Inpatient Only List, HCPCS/CPT code look-up [Preferred]
• Working knowledge of Medicare Guidelines as pertains to the patient in the acute care setting [Preferred]
• Experience in billing cycle language and managed care contract language [Preferred]
• Comfort with interpreting payer guideline language [Preferred]
• Ability to navigate payer website/portals to perform remittance research and gather additional information needs [Preferred]
• Experience in healthcare claims processing and proficiency with medical billing and remittance forms and processes, including 835 and 837 files, and UB04 and CMS-1500 (HCFA) forms [Preferred]
• Technical proficiency within Patient Accounting systems and denial management workflow technology; position requires ability to navigate various modules within applicable technologies to perform account research [Preferred]

Education:

• Associate's of Nursing [Required]
•  Bachelor's of Nursing [Preferred]
• Master's [Preferred]

Field of Study:

• N/A

Work Experience:

• 3+ years experience as RN in an acute clinical setting [Preferred]
• 1+ years experience as RN in acute care setting [Required]

Additional Information:

• N/A

Licenses and Certifications:

• Registered Nurse (RN) [Required]
• Basic Life Support (BLS) [Required]

Physical Requirements: (Please click the link below to view work requirements)

• Physical Requirements -

Pay Range: $65,582.40 - $108,646.85 This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. Create a Job Match for Similar Jobs

At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. More than 100,000 skilled and compassionate caregivers in physician practices, hospitals, outpatient clinics, skilled nursing facilities, home health agencies and hospice centers provide individualized, wholistic care.Our Christian mission, shared vision, common values and focus on whole-person health is our commitment to making communities healthier with a unified system: 51 hospital campuses and hundreds of care sites in diverse markets throughout nine states.

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