Clinical Appeals Spec Lead
Company: Northwestern Medicine
Location: Saint Charles
Posted on: March 12, 2023
- $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
- Develops standard process and procedure.
- Trains new staff and works with manager to monitor quality and
- Monitors EPIC Work queues and distribution of work to eliminate
missed appeal timeframes and to prioritize high dollar risk
- Collaborates with Case Management discussing trends and appeal
failures seeking denial avoidance. This may include CM and/or
- 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
- 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.
- Bachelors degree in Nursing with at least 5 years experience in
acute care setting.
- Knowledge of Utilization Management and level of Care
- 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
- 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
Keywords: Northwestern Medicine, Elgin , Clinical Appeals Spec Lead, Healthcare , Saint Charles, Illinois
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