Summary:

 Identifies and communicates the clinical denials in a timely manner in collaboration and working closely with the physical advisors, Clinical Denial Specialist nurses, Case managers, Case Management Operation Coordinators, and Insurance companies. Sends provider appeals to insurance companies including Medicare and Medicaid for entire network. Provides support in all the administrative and clerical duties to promote efficient and effective department operation. 

Responsibilities:

 1. Reviews new and appeal upheld cases in work queue and incoming fax queue.

2. Reviews denial letters through daily mail.

3. Identifies retro denials and documents appropriately.

4. Notifies new retro denials to nurses in a timely manner.

5. Creates a weekly assignment for director to review for appeals.

6. Communicates with insurance companies to schedule a peer-to-peer review and follow up on the outcomes.

7. Send the appeals with appropriate documents to the payors within the payors’ timeframe.

8. Documents and updates the denials in the denial tracking tool timely and accurately.

9. Collects and analyzes the data as requested.

10. Interacts professionally with team members within the department, other departments, and insurance companies.

11. Demonstrates the ability to be flexible and organizes during stressful situations.

12. Fulfills all compliance responsibilities related to the position.

13. Maintain and Model Nuvance Health Values

14. Demonstrates regular, reliable, and predictable attendance

15. Performs other duties as required. 

Preferred: Bachelor’s degree

Preferred: Previous hospital or other health care setting experience

Working Conditions:

Manual: significant manual skills/motor coordination & finger dexterity

Occupational: Little or no potential for occupational risk

Physical Effort: Sedentary/light effort. May exert up to 10 lbs. force

Physical Environment: Generally pleasant working conditions

Company: Vassar Brothers Medical Center

Org Unit: 1190

Department: Care Coordination

Exempt: No

Salary Range: $20.86 - $38.73 Hourly