NYU Langone

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

Posted on

March 14, 2025

Job Type

Full-Time

Role Type

Clinical Operations

License

RN

State License

New York

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Company Description

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.

Job Description

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.

Requirements

Minimum Qualifications: To qualify you must have a 3-5 years in Clinical RN experience including 2 years of Denial Management or Case Management or related experience and 1-2 years of current experience with reimbursement methodologies. Bachelors Degree Nursing or other Clinical Practice field. Current and valid NYS Registered Nursing License Must have experience with Interqual and or Milliman Disease Management Ideologies. Strong communication (verbal and written) and interpersonal skills. Ability to communicate with multiple levels of the organization; Senior Leadership, Physicians, Directors, Clinical and Support Staff. Demonstrates critical thinking and analytical skills. Ability to work collaboratively in a team environment. Demonstrates the ability to handle multiple assignments and carry out work independently with minimal supervision. Demonstrates responsibility for professional development. Ability to work a flexible schedule to ensure compliance with deadlines. Proficient with Microsoft applications and working knowledge of EPIC and other hospital based clinical computer systems.. Required Licenses: Registered Nurse License-NYS Preferred Qualifications: Experience preparing appeals for clinical denials Certification in Clinical Documentation Improvement Qualified candidates must be able to effectively communicate with all levels of the organization.

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Responsibilities

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.

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