The Clinical Denial Management Specialist is responsible for the identification, mitigation, and prevention of clinical denials. This staff member reviews all initial clinical denials to determine next steps and conducts review &/or appeals as appropriate, such as by reviewing medical necessity, responding to authorization concerns, and/or reconciling coverage-related issues. The clinical denial management 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. Responsible for managing the process of completing collection and accounts receivable activities for denials and for ensuring all hospital collection-related activities meets the General Patient Accounting and Revenue Integrity department's requirements.

RESPONSIBILITIES:

• Must have clinical knowledge and be able to interpret hospital medical documentation.
• Working knowledge and use of evidenced based guidelines.
• Familiarity with medical coding, billing/reimbursement, and/or audit processes.
• Ability to interact with payer representatives and understand contract requirements.
• Familiarity with National Coverage Determinations and Local Coverage Determinations.
• Knowledge of medical necessity screening criteria (e.g., Milliman, InterQual).
• Proficient in EHR and other systems used by organization (e.g., Epic, MedAsset, Microsoft suite or other systems to identify and review patient accounts based on criteria provided).
• Strong time management and prioritization skills.
• Must have demonstrated knowledge of federal and state billing compliance issues for hospitals.
• Must have demonstrated knowledge of billing, reimbursement and collections management.
• Must be able to manage claim denial activities.
• Work requires familiarity working with contracts and payment rules.
• Work requires a high level of problem solving skills.
• Must have working knowledge of utilization management, case management and process improvement.

QUALIFICATIONS/REQUIRMENTS:

The following qualifications are the minimum necessary to adequately perform this job. However, any equivalent combination of experience, education and training which provides the necessary knowledge, skills and abilities would be acceptable, subject to any legal and/or regulatory requirements. At least four to five years of experience required in one of the following areas: Denials, Utilization Management, Case Management, Clinical Documentation Management or any combination preferred. New York State RN license or relevant New York State Clinical license is required. 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.

EDUCATION:

Bachelor Degree in Nursing or Associate Degree in Nursing with clinical specialty certification, Utilization Management or Case Management experience as noted under experience may substitute degree requirements.

OTHER:

If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially i:nfectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.

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About WMC Health

WMCHealth is a 1,900-bed healthcare system headquartered in Valhalla, New York, with ten hospitals on eight campuses spanning 6,200 square miles of the Hudson Valley. WMCHealth employs more than 12,000 people and has nearly 3,000 attending physicians. From Level 1, Level 2 and Pediatric Trauma Centers, the region’s only acute care children’s hospital, an academic medical center, several community hospitals, dozens of specialized institutes and centers, a state of the art Telemedicine program, skilled nursing, assisted living facilities, homecare services and one of the largest mental health systems in New York State, today WMCHealth is the pre-eminent provider of integrated healthcare in the Hudson Valley.

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