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Req. No

77741

Job Title

Clinical Denials Analyst

Market

CHRISTUS System Office

Category

Revenue Cycle

Facility

CHRISTUS Corp Irving Offices 919 and 909 Buildings

Address

919 Hidden Ridge
Irving, TX  75038
USView On A Map View Other Locations

Type

FULL TIME

Clinical Denials Analyst Job in Irving

Summary:

The Clinical Denials Analyst reports to the System Medical Director for Physician Advisory Services and acts as an intermediary between the clinical care team and the Revenue Cycle Appeals Department. This individual will work with the local Utilization Review (UR) teams to review new clinical denials to help determine their root cause, collect relevant information from the care team to aid in the appeals process, and escalate cases requiring Physician Advisor intervention. The successful candidate will demonstrate the ability to locate, research, comprehend and appropriately apply 3rd party payer rules and regulations to case reviews. This will require staying current with payor policy changes and communicating relevant information to key stakeholders in the denials and appeals process. This individual will also be responsible for working in collaboration with the appeals department to trend denials outcomes to facilitate associate education in conjunction with the leaders of clinical departments across the system. 

  • Maintains general medical-surgical and ICU clinical knowledge
  • Identifies and tracks/trends reasons and root causes for denials
  • Identifies and communicates opportunities for improved performance to stakeholders including but not limited to: Utilization Management, Pre-Access, Billing & Coding, CDI, etc.
  • Leads orientation of new staff in accordance with departmental guidelines
  • Identifies methods to avoid denials and works in collaboration with clinical appeals to report trends to Revenue cycle team and to other pertinent leaders
  • Tracks and monitors front-end activities in the acute care setting that influence the clinical denials/appeals process, seeking opportunities for continuous improvement
  • Returns appeal requests for denials determined to be technical or those received after the deadline has passed to CBO with explanation
  • Works with the appeals team to track and analyze denials into categories; reason, day of stay, physician, payer, DRG or MDC, and care unit. Incorporates PAD analysis of findings in appropriate manner
  • Identifies barriers to achievement of departmental goals related to denial management and appropriately reports those suggestions for improvement
  • Leverages critical thinking to identify trends within grievance, appeal, and other clinical data sources
  • Creates actionable analysis and identifies the most effective party to address any identified issues with minimal supervision
  • Identifies, tracks, and initiates internal training on Denials and Appeals as determined by the internal quality management reviews
  • Reviews first level appeal decisions to ensure first level appeal reviewers are applying service definitions and clinical guidelines when making appeal determinations
  • Train associates on quality assurance reporting requirements, assist in goal setting and standardization of productivity and performance monitoring
  • Collects and synthesizes relevant information through the system to support denial prevention strategies enterprise-wide
  • Creates and presents analyses of short-term studies using clear and direct language to explain trends and areas of opportunity to management and other staff Performs other related duties as assigned

Requirements:

  • Bachelor of Science degree in Nursing — PREFERRED
  • Associates Degree in Nursing with insurance or hospital case management experience will be considered.
  • Current license to practice professional nursing in the states of Texas and/or Louisiana or compact eligible license— REQUIRED for Nursing professionals
  • Current license from respective agency for non-nurse professionals- CCM or ACM Certification in Case Management — PREFERRED
  • Proficiency with Microsoft Excel - PREFERRED
  • Minimum 3 years of utilization review experience is needed

Work Type: 

Full Time


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Clinical Denials Analyst