Clinical Denial Management RN

***Requires 2 weeks of in-office training in Champaign, IL, then fully remote***

The Clinical Denial Management - RN participates in clinical review and development of well-constructed appeal arguments for reconsideration of medical services that may have been denied. Denial of payment may be based on insufficient clinical documentation to support the level of care, utilization review, determination that a treatment is investigational/experimental, and/or that the treatment rendered is not medically necessary.

Certifications: Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR)Illinois Department of Financial and Professional Regulation (IDFPR); Certified Case Manager within 2 years - Commission for Case Manager Certification (CCMC)Commission for Case Manager Certification (CCMC) OR Nursing Case Management Certification (CMGT-BC) within 2 years - American Nurses Credentialing Center (ANCC)American Nurses Credentialing Center (ANCC)

Education: Bachelor's Degree; College Diploma: Nursing (If no BSN, BSN within 3 years of start date)

Work Experience: Nursing

The Clinical Denial Management - RN will review the case, and determine the potential for an appeal on a denied claim.Create quality appeal letters to achieve maximum overturn rate. The appeal letter will be written in an objective narrative form, utilizing appropriate formatting, appropriate English grammar, based on current evidenced based criteria, medical literature if applicable, healthcare statutes, and clinical judgment.Stays abreast of regulatory changes and payer policies.Utilizes evidenced based criteria and other resources to develop sound and well-supported appeal arguments.Performs duties in accordance with the ethical and legal compliance standards as set by Carle Health, and all regulatory agencies, including State and Federal.Maintains strictest confidentiality of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).Focuses on the review and analysis of governmental denial rationales and provides appropriate medical necessity appeal services.Review governmental contractors response letter in comparison to the medical records.Researches medical literature and evidence based medical publications to support the level of care provided.Reviews/audits medical necessity denials looking for patterns by services or by the physician.Works with leadership to improve clinical documentation, understand root causes, and to reduce denials.Works collaboratively with health information management coding staff, physicians and financial services to resolve payment denials and clinical documentation issues.Adept at working in a fast paced, collaborative environment with multi-disciplinary teams across the institution.Ensures quality and productivity standards are met or exceeded.Functions effectively within a team and participates and contributes constructively to produce results in a cooperative effort.Ensure workload is completed in an efficient and timely manner.Participates in projects as needed.Write denial letters to payers. Communicate with insurance companies. Review chart and determine denial reason.

Find it here.

Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.

Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We've grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We're developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world's first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet designations, the nation's highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.