Clinical Appeals Specialist

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Position

Req #: 9923
Category: NURSING/LVN (INPATIENT, OUTPATIENT, SPECIALTY)
Division: Finance
Employment Type: Full Time
Shift: Day
Hours:
Compensation Type: Salaried
Facility: JPOC 1350
Location: 1350 S. Main Street, Fort Worth, TX

Description

Description: The Clinical Appeals Specialist is responsible for the identification, mitigation, and prevention of clinical denials. This position reviews all initial clinical denials to determine next steps and conducts appeals as appropriate, such as reviewing medical necessity, responding to authorization concerns, and/or reconciling coverage-related issues. The Clinical Appeals Specialist also works to prevent future clinical denials by communicating with clinical and revenue cycle leadership about denial root causes, such as documentation gaps or insufficient charge capture, and helps develop and implement staff education and process changes. Typical Duties:

  1. Reviews clinical denials and initiates appeals process, if determined appropriate according to internal guidelines.
  2. Conducts medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals.
  3. Communicates with payer representatives or other stakeholders in appeals process (e.g., mediators, arbitrators, legal counsel).
  4. Provides the business services department with assistance in resolving problems that require medical expertise.
  5. Monitors and follows up on appeals throughout entire process, determining next steps to ensure appeals either result in an overturned denial or have proceeded as far as possible.
  6. Maintains a monthly log of audit results and error ratios; turns in printed report every month to the Business Services Supervisor.
  7. Identifies gaps in clinical documentation and works with clinical staff to develop and implement quality improvement and staff education initiatives.
  8. Assesses the quality of charge capture and coding as they relate to clinical denials; assists revenue cycle leadership in improving processes.
  9. Assists interdepartmental teams in troubleshooting accounts that are being held in A/R due to charging/documentation discrepancies.
  10. Assists case management with concurrent review processes.
  11. Supports billing staff by reviewing high-risk and/or high-dollar accounts before claim submission to prevent clinical denials.
  12. Analyzes initial and fatal denial data to identify trends; shares findings with revenue cycle leadership to drive process improvements.
  13. Supports global denial prevention and mitigation efforts throughout JPS Health Network, such as attending denial task force meetings.
  14. Performs other job related duties as assigned.

Qualifications

Qualifications:

    Required Education and Experience:

  • Graduate from an accredited School of Vocational Nursing or Bachelor’s Degree in Nursing from an accredited school of professional nursing.
  • Minimum three years of experience in a clinical environment, case management, denials, or billing.
  • Required Licensure/Certification/Specialized Training:

  • Current RN or LVN licensure by the Board of Nurse Examiners for the State of Texas or proof of reciprocity of licensure between the State of Texas and another state.
  • Preferred Education and Experience:

  • Bachelor’s Degree in Nursing from an accredited school of professional nursing.
  • Preferred Licensure/Certification/Specialized Training:

  • Certification in at least one of the following preferred: certified healthcare chart auditor, certified professional in utilization review (or utilization management or healthcare management), certified case manager, certified documentation specialist, certified coder, certified professional medical auditor, or similar program.

About

JPS Health Network is a $950 million, tax-supported health care system for Tarrant County in North Texas. Licensed for 578 beds, the network includes an acute care hospital and more than 40 community-based clinics, including 19 school-based clinics. John Peter Smith Hospital is home to Tarrant County’s first and only Level 1 Trauma Center, its only psychiatric emergency services site and has the largest hospital-based family medicine residency program in the nation. Our network employs more than 6,500 people.

Acclaim is our multispecialty medical practice group. Acclaim has over 300 providers serving the JPS Health Network in specialties ranging from primary care to general surgery and trauma. The Acclaim group has been formed around a common set of incentives and expectations supporting the operational, financial and clinical performance
outcomes of the network. Our goal is to provide high quality, compassionate clinical care for every patient, every time.

For more information, visit www.jpshealthnet.org .
To view all job vacancies, visit www.jobs.jpshealthnet.org/ or www.teamacclaim.org .
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