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Job Details

Clinical Appeals Specialist

Company name
Maine Medical Center

Location
Scarborough, ME

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Job Description:

Position Summary

The Clinical Denials Appeal Specialist is responsible for investigating clinical denials for all MaineHealth Hospitals on Epic as well as writing and tracking of appeals for additional recoupment of lost revenue. Using LEAN process innovation principles, works closely with Insurance Payors, Clinical Departments/Leadership and Revenue Cycle Leadership to identify root cause issues, reduce denials, and improve upon the Revenue Cycle?s goal of increasing the percentage of net A/R collected within a 120 day timeframe. This role will also be responsible for assessing Additional Development Requests from Medicare for compliance risk, ensuring records are accurate and complete, and providing feedback to leadership on identified issues/risks.

Required Minimum Knowledge, Skills, and Abilities (KSAs)

* Licensed as a Registered Nurse (RN) in the State of Maine.

* Bachelor's Degree in Nursing preferred.

* Acute managed care experience preferred.

* Certification in Case Management, Quality Management, or Utilization Management preferred.

* Current knowledge of the rules and regulations as they relate to State and Federal Government and 3rd Party Payors. Including an in depth understanding of Medicare's LCD and NDC medical necessity guidelines, appeals process and timelines.

* Knowledge of broad range of medical and psychiatric diagnoses, current treatment modalities, therapeutic service and intervention techniques.

* Interpersonal skills sufficient to communicate effectively with a variety of clinicians, hospital personnel, and well as third party reimbursement personnel.

* Ability to take initiative; be self directed and exercise consistently sound judgment in making appropriate decisions regarding denials and appeals.

* Ability to communicate effectively, using a high degree of diplomacy and sensitivity in verbal and written communication in order to achieve the desired outcome.

* Ability to work under pressure, and to maintain patience in difficult situations as well as to cope with a high volume work load.

* Ability to adapt to new or consistently challenging problems, procedures, and policies.

* Familiarity with medical records, health information management systems.

* Acquired skills with Microsoft Excel, Word, and PowerPoint.

Company info

Maine Medical Center
Website : http://www.mmc.org

Company Profile
One of the country’s consistently highest rated hospitals is right in your own backyard. Maine Medical Center is the state’s premier referral hospital, offering services not available elsewhere, and also serves as a community hospital for Greater Portland. MMC was rated the fourth safest hospital in the U.S. and our nursing staff was recently rated in the top 3 percent in the world for nursing excellence. Which just proves what we’ve always known - in Maine, the grass is greener on both sides of the street.

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