Specialist, Clinical Denials and Appeals (RN)-Oncology (****remote available****)

NYU Langone Health is a world-class, patient-centered, integrated academic medical center, known for its excellence in clinical care, research, and education. It comprises more than 200 locations throughout the New York area, including five inpatient locations, a children’s hospital, three emergency rooms and a level 1 trauma center. Also part of NYU Langone Health is the Laura and Isaac Perlmutter Cancer Center, a National Cancer Institute designated comprehensive cancer center, and NYU Grossman School of Medicine, which since 1841 has trained thousands of physicians and scientists who have helped to shape the course of medical history. At NYU Langone Health, equity, diversity, and inclusion are fundamental values. We strive to be a place where our exceptionally talented faculty, staff, and students of all identities can thrive. We embrace diversity, inclusion, and individual skills, ideas, and knowledge. For more information, go to nyulangone.org, and interact with us on LinkedIn, Glassdoor, Indeed, Facebook, Twitter, YouTube and Instagram.

We have an exciting opportunity to join our team as a Specialist, Clinical Denials and Appeals (RN). In this role, the successful candidate under the general supervision of the Director and team Senior Specialists, the Clinical Denials and Appeals Specialist performs advanced level work related to Clinical Denial Management. Responsible for managing clinical denials by conducting a comprehensive review of clinical documentation and formulating a timely and defensible written response based on clinical documentation, evidence based medical necessity criteria, physician documentation and medical policies of the payor. Communicates identified denial trends and patterns to Clinical Denials and Appeals Director. Works to review, evaluate and improve the enterprise clinical denial and appeal process.

Researches and reviews payor denials related to referral, authorizations, level of care and medical necessity and formulates and submits appeal letters utilizing relevant and effective clinical documentation, evidence based medical necessity criteria, medical policies of the payer, and community and national medical management standards and protocols. Assists with the coordination and collaboration with hospital departments (Case Management, Health Information Management and Clinical Documentation Improvement, Inpatient and Outpatient Revenue Services, etc) as clinical reviews are performed. Collaborates with Physician Advisors to appropriately identify clinical denials that require escalation. Documents in appropriate tracking tool for maintenance and distribution of reports as needed by leadership. Identifies denial patterns and escalates to management as appropriate with sufficient information for additional follow up, and or root cause resolution. Makes recommendations for additions/revisions/deletions to work queues and claim edits to improve efficiency and reduce denials. Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalates potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership, as appropriate. Maintains clinical expertise and trends in healthcare, reimbursement methodologies, and utilization management specialty areas by participating in professional organizations, seminars and educational programs. Attends enterprise hospital meetings under the direction of the Clinical Denials and Appeals Manager.