Denials and Appeals Analyst

The Denials and Appeals Analyst provides appeal and resolution of coding and billing related payor claim denials for hospital-based services. Manages the denial and appeal process cycle (includes all necessary appeal activities including intake, processing, researching, writing, tracking, educating, etc.).

1. Maintain current knowledge of coding, compliance, and documentation guidelines and specifically proficiency in hospital coding systems: ICD (International Classification of Diseases), CPT (AMA Procedural Coding) and HCPCS Level II (Healthcare Common Procedural Coding). 
2. Research authoritative resources to ensure compliance with documentation requirements necessary to support hospital charging practices.
3. Develop and maintains professional relationships with both external and internal customers (i.e., payors, associates, Clinicians, Directors, and Physicians).
4. Provide practical, appropriate, and cost-effective recommendations to management relating to process improvement and audit findings implications.
5. Consistently document relevant facts and information to support the work performed and the resulting conclusions using spreadsheets and audit findings.
6. Prioritize and organize multiple concurrent open audits while still providing quality customer service to financial and clinical departments.
7. Understand financial, operational, and compliance risks of processes when making corrective recommendations.

 

• High School Diploma required; Bachelor Degree is preferred.
• CPC Certification or Certified Outpatient Coding (COC) is required. 
• Certification in hospital billing from a recognized national program (i.e., AHIMA, AAHAM, etc.). is preferred.
• Certified Professional Medical Auditor (CPMA) is preferred.
• Minimum five years of hospital procedure coding experience is required.
• Claim auditing experience is preferred.

Clinical experience is preferred.

 

Nemours Children’s Health is an internationally recognized children’s health system. With more than 1.7 million patient encounters annually, we provide medical care in five states through two freestanding state-of-the-art children’s hospitals — Nemours Children’s Hospital, Delaware and Nemours Children’s Hospital, Florida. Our pediatric network includes 80 primary-urgent-and specialty care practices and more than 40 hospitalists serving 19 affiliated hospitals. We generate annual revenues of more than $1.7 billion derived from patient services, contributions from the Alfred I. DuPont Trust, as well as other income.

As one of the nation's premier pediatric health systems, we’re on a journey to discover better ways of approaching children’s health. Putting as much focus on prevention as cures and working hand in hand with the community to make every child’s world a place to thrive. It’s a journey that extends beyond our nationally recognized clinical treatment to an entire integrated spectrum of research, advocacy, education, and prevention, leading to the healthiest generations of children ever.

Equity, diversity, and inclusion guide our growth and strategy. We are looking for individuals who are passionate about, and committed to, leading efforts to provide culturally relevant care, reducing health disparities, and helping build a diverse and inclusive environment. All of our associates are expected to ensure that these philosophies are embedded in their day-to-day work with colleagues, patients and families. 

To learn more about Nemours Children’s and how we go well beyond medicine, visit us at www.nemours.org.