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Clinical Appeals Spec Lead

Company: Northwestern Medicine
Location: Saint Charles
Posted on: March 12, 2023

Job Description:


  • $10,000 Tuition Reimbursement per year ($5,700 part-time)
  • $6,000 Student Loan Repayment ($3,000 part-time)
  • $1,000 Professional Development per year ($500 part-time)
  • $250 Wellbeing Fund per year($125 for part-time)
  • Annual Employee Merit Increase and Incentive Bonus
  • Paid time off and Holiday payDescriptionThe Clinical Appeals Spec Lead reflects the mission, vision, and values of NMHC, adheres to the organizations Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.Responsibilities:Inpatient and Clinical OP Denial Management in Revenue Cycle:
    • Assures appropriate, accurate and timely review of all denials and account balances related to denials including payer denial management and appeal.
    • Maintains accurate and keeps current with payer appeals processing requirements.
    • Develops standard process and procedure.
    • Trains new staff and works with manager to monitor quality and productivity.
    • Monitors EPIC Work queues and distribution of work to eliminate missed appeal timeframes and to prioritize high dollar risk cases.
    • Collaborates with Case Management discussing trends and appeal failures seeking denial avoidance. This may include CM and/or physician education.
    • Evaluates appropriate level of care using Milliman and Interqual standards as well as CMS rules and regulations.
    • Assists in the collection and reporting of financial and revenue cycle indicators as it relates to denials and performance again level of care guidelines.
    • Analyzes information gathered from the appeal process and looks for system opportunities to improve timeliness or denial avoidance.
    • Creates reports for Revenue Cycle leadership and payer meetings. Develops and maintains payer issue spreadsheets and works with all escalation processes to secure payment (ie. Payer representatives, Managed Care Liaisons, Clinical or Revenue Cycle managers and Directors, etc.
    • Using analytics, develops processes and workflows to avoid and/or eliminate High Risk cases.
    • AA/EOE.QualificationsRequired:
      • Bachelors degree in Nursing with at least 5 years experience in acute care setting.
      • Knowledge of Utilization Management and level of Care guidelines.
      • Basic knowledge of Insurance payer clinical policies.
      • Proven leadership skills to affect positive work environment and exceptional outcomes.
      • Analytical skills necessary to independently collect, analyze and interpret data, resolve problems requiring innovative solutions.
      • Basic computer skills.Preferred:
        • 2 years of Revenue cycle experience in Denials Management.
        • 2 years of experience in EPIC.Equal OpportunityNorthwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.

Keywords: Northwestern Medicine, Elgin , Clinical Appeals Spec Lead, Healthcare , Saint Charles, Illinois

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