DENIAL MGMT CLINICAL ANALYST
DEPT: CLINICAL DENIALS ADMIN
Full-Time / DAY SHIFT
The Denials Management Clinical Analyst (DMCA) is a registered professional nurse with knowledge and expertise in process analysis, clinical outcome data analysis, utilization management, and utilization of information systems. The DMCA is knowledgeable regarding changes in care delivery and their impact on third party reimbursement. The DMCA has clinical expertise either as generalist or with a specific patient population. The DMCA’s role is to support clinical and financial integration across the continuum and the care management team.
The DMCA works collaboratively with Managed Care contracting staff, revenue cycle staff, Center for Status Integrity (CSI) team members, and other internal and external customers. The DMCA is responsible for resolving third party payor denials and identifying denial trends by payer. The DMCA is knowledgeable of third party payer contracts, Medicare and Medicaid guidelines, and other regulations which impact the utilization or denial of provider services.
Essential Duties & Functions:
1. Responds positively to, and adapts to, department and organizational changes.
2. Knowledgeable of relevant state and federal laws/statutes/regulations pertaining to utilization, quality or reimbursement, and how those impact care at the point of service.
3. Knowledge of clinical practice guidelines and appropriateness of clinical interventions.
4. Performs medical record review, abstracting, aggregating, analyzing, interpreting and reporting complex clinical data obtained from the record.
5. Compares data form the inpatient records to established criteria, determining legitimacy of admission, treatment, status, and length of stay.
6. Prepares organized, clear, concise, accurate and informative written correspondence to the payer, analyzing the specified issues and clearly outlining the organization’s expectations.
7. Accurately tracks in denials system actions taken to resolve denials and outcomes of those actions.
8. Identifies clinical documentation, quality or legal issues and communicates those issues to the department leadership.
9. Communicates clearly and collaborates effectively with internal and external customers.
10. Utilizes facts, negotiation skills, persuasive abilities, adaptability and flexibility in resolving issues with internal and external customers.
11. Has knowledge of 3rd party payer contracts, their terms, and how these impact point of service.
12. Utilizes critical thinking skills in the identification of denials, analysis of denials, resolution of denials, and prevention of denials.
13. Performs calculations to determine expected reimbursement, identify contractual adjustments, and evaluate the application of contract terms.
14. Manage projects assigned by department leadership
15. Defines opportunities to improve denials management processes and department performance.
Minimum Level of Education Required: Bachelor's degree
Additional requirements:
Type of degree: Nursing
Area of study or major: N/A
Licensure/Certification/Registration
§ Registered nurse with valid Ohio license. Certification in area of clinical specialty preferred
Experience
Minimum Level of Experience Required: 3 - 5 years of job related experience
Prior job title or occupational experience: Case management, Utilization review
Prior specific functional responsibilities: N/A
Preferred experience: Knowledge of hospital reimbursement, third party billing, government rules and regulations
Other experience requirements: Knowledge of InterQual and MCG, performance improvement, Medicare rules and regulations
Knowledge/Skills
Personal computer skills required, including use of Microsoft Word, Microsoft Excel, EPIC
Experience in gathering information, monitoring indicators, and feedback mechanisms is required.
Strong interpersonal skills required
Ability to research, evaluate information, analyze problems and make appropriate recommendations required
Demonstrated conflict resolution skills required
Assertive communication skills required