Under the direction on the Chief Medical Officer, VP of Behavioral Health Services and the Director Patient Financial Services, the Clinical Denials Coordinator addresses clinical payment denials and intervenes to maximize reimbursement for the services rendered by the hospital.
This position also serves as a clinical expert on medical necessity criteria, inpatient/observation criteria, Medicare/Medicaid rules and regulations and emergency criteria for the Federal Emergency Services program.
Requires a Bachelor's degree in Nursing or related field.
Must have a minimum of three (3) years' of progressively responsible case management experience, predominately in an acute care setting, that demonstrates a strong understanding of the required knowledge, skills and abilities.
Prefer three to five (3-5) years' experience in utilization management and/or one to two (1-2) years' experience in denials management and claim disputes within an acute care setting or payer environment.
Must possess a current, valid AZ RN license; temporary AZ RN license; or valid compact RN licensure for current state of practice.
Must also be in good standing with the issuing Board of Nursing.
Certification in Utilization Review and/or Case Management is preferred.
Knowledge, Skills & Abilities:
Requires a broad clinical background and expertise in Adult & Pediatric Acute Care InterQual® Level of Care Criteria.
Must also be familiar with inpatient behavioral health admission criteria and the court ordered process for mental health treatment in the state of Arizona.
Requires analytical and critical thinking skills which take into consideration additional factors that support medical necessity for inpatient/observation services.
Must be knowledgeable of Medicare/Medicaid rules & regulations, AHDS/DBHS RBHA guidelines, and commercial payer coverage guidelines and possess a strong understanding of the claim dispute process for the various payers.
Must possess strong oral and written communication skills.
Must have the ability to maintain professional rapport with physicians and possess strong interpersonal skills with the ability to communicate effectively with all levels of staff to secure clinical and non-clinical information required to dispute medical necessity denials.
Requires excellent organizational skills and the ability to work independently.
Requires effective negotiating skills and the ability to resolve difficult claim issues.
Must have strong computer skills including Microsoft Office, Microsoft Word, and Microsoft Excel.
Knowledge and experience with Epic and Midas+ is preferred.
Requires the ability to read, write and speak effectively in English.
Location: Valleywise Health System · Patient Financial Services
Schedule: Regular PT 20 Hours Per Week, Days
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