Senior Clinical Appeals Specialist

Senior Clinical Appeals Specialist (RN)

Reporting to the Associate Director of Revenue Integrity at Stony Brook Medicine the Senior Clinical Appeals Specialist will investigate outpatient clinical appeals requests originating from the Hospital’s Business Office; review applicable payer medical policy/guidelines, claims and pre-authorization data and medical records; identify the payer’s basis for the denial; and create a compelling written appeal which leverages clinical documentation, third-party payer medical policy and contract language for support.

Summary:

• Analyzes and interprets clinical denials received through the Hospital’s Business Office to identify opportunities for appeal.
• Authors and submits timely, well-prepared appeals, including supporting documented clinical evidence, coding guidelines and payer medical policy, as appropriate.
• Completes physician queries, as required.
• Prepares all case documentation using XR Clinical Reporting system and packages into a PDF case file to submit for decision.
• Tracks and reports on denial trends, appeals status and final outcomes.
• Identifies clinical denial root cause and partners with Patient Financial Services, HIM, Clinical Documentation Improvement, and service departments to develop denials prevention and mitigation strategies, education, and process improvement.
• Collaborates with CDI and others on the development of training tools to educate clinical and revenue cycle staff on reasons for denials, proper coding and clinical documentation to prevent denials.
• Audits third party vendors to ensure clinical appeals opportunities are identified and realized.
• Special projects, as requested.

Required Qualifications:

• Registered Nurse (RN) Bachelor’s degree in Nursing with 5+ years in clinical practice experience.
• Three or more years denials management, appeals, clinical documentation review/chart audit or equivalent experience.
• Demonstrated ability to research and resolve difficult clinical denial and documentation issues.
• Strong knowledge of ICD-10- CM, HCPCS / CPT4 coding and use of modifiers.
• Ability to research and understand Medicare LCD / NCD and commercial coverage policies.
• Familiarity with the NCCI Policy Manual and CCI Edits.
• Experience with outpatient billing requirements and CMS Medicare and NYS Medicaid reimbursement methodologies.
• Excellent written and verbal communication skills including the ability to convey complex clinical concepts.
• Proficiency in MS Office Suite; including Word and PowerPoint.

Preferred Qualifications:

• Medical Coding Certification through AAPC or AHIMA; CCS, COC.
• Outpatient hospital coding experience.
• Clinical Documentation Specialist Certification; CCDS, CCDS-O.
• Knowledge of Managed Care Payer Contracts and Medical Policy.
• Experience with acute care hospital claims analysis and edit resolution.

Special Notes: Resume/CV should be included with the online application.

In accordance with federal and state regulations that all hospitals and nursing homes require personnel to be vaccinated against COVID-19, candidates who are not already fully vaccinated must obtain the first dose of a COVID-19 vaccine within three (3) calendar days of acceptance of a conditional job offer and must obtain any subsequent doses in accordance with that particular vaccine manufacturer’s protocol. Candidates who are partially vaccinated, but not yet fully vaccinated, must complete their vaccination series within three (3) calendar days of a job offer or in accordance with that particular vaccine manufacturer’s protocol, whichever comes later.

The state regulation also includes those who may be affiliated with or interact with employees of a hospital or nursing home. The regulations allow for limited exemptions with reasonable accommodations, consistent with applicable law.

Posting Overview: This position will remain posted until filled or for a maximum of 90 days. An initial review of all applicants will occur two weeks from the posting date. Candidates are advised on the application that for full consideration, applications must be received before the initial review date (which is within two weeks of the posting date).

If within the initial review no candidate was selected to fill the position posted, additional applications will be considered for the posted position; however, the posting will close once a finalist is identified, and at minimal, two weeks after the initial posting date. Please note, that if no candidate were identified and hired within 90 days from initial posting, the posting would close for review, and possibly reposted at a later date.

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• Stony Brook Medicine is a smoke free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.
• All Hospital positions maybe subject to changes in pass days and shifts as necessary.
• This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.
• This function/position maybe designated as “essential.” This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities.

Prior to start date, the selected candidate must meet the following requirements:

• Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services*
• Complete electronic reference check with a minimum of three (3) professional references.
• Successfully complete a 4 panel drug screen*
• Meet Regulatory Requirements for pre employment screenings.
• Provide a copy of any required New York State license(s)/certificate(s).

Failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.

• The hiring department will be responsible for any fee incurred for examination.

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Stony Brook University is committed to excellence in diversity and the creation of an inclusive learning, and working environment. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, familial status, sexual orientation, gender identity or expression, age, disability, genetic information, veteran status and all other protected classes under federal or state laws.

If you need a disability-related accommodation, please call the University Office of Equity and Access at (631)632-6280.

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