Senior Denials RN Specialist

Ensemble Health Partners is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country. Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference! O.N.E Purpose: Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations. Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation. Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results.

CAREER OPPORTUNITY OFFERING: Bonus Incentives Paid Certifications Tuition Reimbursement Comprehensive Benefits Career Advancement This position pays between $62,500.00 - $79,800.00/ based on experience The Sr Specialist Denial RN prepares appeals for clinical and technical claim denials across all client hospital facilities. Job duties include but are not limited to: understanding insurance contract terms, reviewing claim denials and underpayments to determine if additional payment amounts can be expected, analyzing medical records and determining if a member or an Independent Review organization (IRO) appeal is necessary, understanding payer medical policy guidelines, preparing IRO appeal documentation which may include correcting and resubmitting claims, gathering additional information, reviewing medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting provider, member and IRO/ALJ appeals in a timely manner. Knowledge and understanding of ERISA compliance laws, healthcare provider and member's legal rights regarding member appeal and grievance processes. Ensures compliance with HIPAA regulations. In addition, the Sr Specialist Denial RN will work closely with the Clinical Appeal team and Case Management Department to ensure denial trends and outcomes are communicated in a timely manner. Serves as a mentor and provides necessary training and education to Clinical Denial and Underpayment team members. The Sr Specialist Denial RN will perform these duties while meeting Ensemble principles, as well as meeting the regulatory compliance requirements.

Sr Specialist Denial RN primary responsibility is the review of complex claims and escalating clinical or technical claim denials for potential provider, member level or IRO/ALJ appeal. Extensive review of medical records for medical necessity criteria, filing written letters of appeal on denied claims, filing complaints with state Department of Insurance, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner. Reviewing claim denials and underpayments to determine if additional payment amounts are expected and identifying trends in payment discrepancies amongst payors. Work closely with the Clinical Denial team and Case Management Department to ensure denial trends and outcomes are communicated in a timely manner. Acts as a mentor and provides necessary training and education to Clinical Denial and Underpayment team members. Performs other duties as assigned.