RN, Clinical Denials Specialist

Located in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate and connect.

Whether virtual or on campus, Adventist Health Roseville and shared service teams have access to enjoy a welcoming space designed to promote well-being and inspire your best work.

Job Summary:

Utilizes clinical expertise, insurance knowledge, business know-how and high-level communication to analyze the patient’s encounters, medical records, and invoices to assist with the resolution of retrospective approval for denied services and possibly continued access needs. Supports the execution of system-wide strategic initiatives, process re-design, root cause analysis, metric/report development as it relates to clinical reviews and denial management. Analyzes, monitors, reports findings, and provides recommendations on clinical denials to AH Leadership. Works closely with appropriate departments to review and obtain the medical documentation required to expedite the denial appeal process. Communicates the appropriate denial information at the department and system level to ensure that system-wide and market specific mitigation action plans are created and implemented to resolve root cause issues and reduce denials. Supports and facilitates the design, implementation of Utilization Management data collection methodologies and Utilization Management Committee.

Job Requirements:

Education and Work Experience:

• Associate's Degree in Nursing: Required
• Bachelor's Degree in Nursing (BSN): Preferred
• Three years' experience in an Acute Care Hospital: Preferred
• Three years' experience in Utilization Management/Case Management, or related field: Preferred
• Three years' experience with InterQual and/or MCG for acute care hospital population: Preferred

Licenses/Certifications:

• Registered Nurse (RN) licensure in the state of practice: Required

Essential Functions:

• Researches payer clinical denials related to referral, pre-authorization, medical necessity, case management, non-covered services, and billing resulting in denials and delays in payment. Maintains confidentiality of information in compliance with hospital policies and HIPAA.
• Reviews clinical denials by all payers, government and commercial, and validates the denial reason and ensures the denial reason is accurately applied. Generates appeals based on the disputed reason and contract terms specific to the payer. Follows the payer’s denial guidelines for appeal submission. Develops relationships with payer representatives and key AH contacts to support the expeditious overturn of denials.
• Educates key healthcare providers such as physicians, nurse practitioners, allied health professionals, nursing and care coordination regarding clinical documentation improvement, documentation guidelines and the need for accurate and complete documentation in the health record. Stays abreast of regulatory changes and payer policies.
• Identifies and escalate consistent issues and trends with payers to support AH leadership in meeting with payers to resolve issues. Generates clinical denial reports on a regular basis and provides updates to AH Leadership.
• Assists with developing and maintaining denial and appeal dashboard and performance tools for ongoing reports and acts as a liaison to the Utilization Management Committee. Attends InterQual educational sessions and maintains education and learning on current practices. Completes yearly IRR testing and maintains a high-level competency rate.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations, including, but not limited to, measles, mumps, flu (based on the seasonal availability of the flu vaccine typically during October-March each year), COVID-19 vaccine (required in CA, HI and OR) etc., as a condition of employment, and annually thereafter. Medical and religious exemptions may apply.

Adventist Health is a faith-based, nonprofit, integrated health system serving more than 90 communities on the West Coast and Hawaii with over 400 sites of care, including 26 acute care facilities, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of 37,000 includes employees, physicians and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.