Clinical Denial Management Assistant [United States]

 

Position Summary:
The Clinical Denial Management Assistant provides support to the Clinical Denial Management and Utilization Review teams. This role is pivotal in the clinical denial appeal process. Provides support before the creation of the appeal and after the appeal is sent to the payer. The Assistant helps with tracking of key information related to the life span of the clinical appeal.

Qualifications:

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EDUCATIONAL REQUIREMENTS
None specified

CERTIFICATION & LICENSURE REQUIREMENTS
None

EXPERIENCE REQUIREMENTS
Three (3) years of healthcare experience. Minimum one (1) year of recent experience working with healthcare utilization management, insurance denials, health insurance authorizations, or care coordination.

SKILLS AND KNOWLEDGE
Ability to type, organize and manage in-depth data with attention to detail. Ability to acquire working knowledge of program specific computer applications. (Word, and excel/spreadsheets, EPIC/CORTEX) Good problem solving skills, self-directed, and able to complete required assigned work independently. Effective interpersonal and communication skills with individuals in diverse professional and patient groups.

Essential Functions:

• Communicates effectively with Clinical Denial Management and Utilization Review teams to ensure denial letters are addressed in a timely manner.
• Reviews denials sent by payers and documents them into the Cortex software, EMR and/or tracking tool as appropriate to ensure appropriate tracking is maintained.
• Communicates with Clinical Denial Management and Utilization Review teams to help create strong processes and efficiencies.
• Submits all appeal documents to the payer accurately and timely.
• Organizes and maintains all clinical appeal documents, databases, and records in a systematic way.
• Reviews appealed cases in a systematic and timely fashion to ensure payment is received and notifies Clinical Denials Management team of new findings of review.
• Contacts insurance provider as directed when more information is needed.
• Gathers data for reporting purposes.
• Screens incoming calls, faxes or other digital communications related to clinical denials and directs it to the appropriate area.
• Perform projects, reviews and handles reports as assigned.
• Interacts with hospital, provider, and financial staff regarding determinations, appeals, and denials and gives direction as necessary.

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.

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