Clinical Denial and Appeals Specialist

The Clinical Denial and Appeals Specialist work collaboratively with Tenet Clinical Documentation Improvement and Coding operations, Conifer Revenue Cycle, Tenet Managed Care, and Tenet Clinical Operations to effectively appeal clinical denials. The incumbent also tracks, trends, and analyzes denial information to identify improvements opportunities that reduce future denials.

Responsibilities:

• Interprets clinical denials and formulates appeal letters by following the Rapid Response denial process in collaboration with appropriate Tenet and Conifer team members.
• Analyzes and tracks clinical denial data to identify trends in payer denials and recommends process improvements for denial reduction. Reports clinical denial data monthly to key-stakeholders.
• Performs CDI DRG Reconciliation processes.
• Provides recommendations and education to CDI, Coding, and RCM leadership as a result of process and documentation improvement opportunities that are resulting in clinical denials.
• Works closely with Tenet’s Managed Care Department to ensure alignment on payer denial trends, improvement opportunities, and supports denial meetings involving payers.

Qualifications:

• Expert level clinical appeal writing skills
• Expert level ability to create clear and concise reports, and effectively communicate results
• Maintain productivity standards
• Must be detail oriented and can work independently and in team setting across various disciplines
• Moderate skills in MS Excel and PowerPoint, MS Office
• Must display excellent interpersonal skills
• Ability to demonstrate initiative and discipline in time management and assignment completion
• Ability to research difficult clinical denial and documentation issues and follow through to resolution
• Ability to manage time effectively and prioritize assignments and projects
• Ability to work in a virtual setting under minimal supervision

Required:

• Bachelor’s degree in Nursing
• 5+ years of experience in a clinical field of practice
• 3-5 years of experience effectively writing clinical appeals and denial management
• Active, current, and unrestricted RN license

Preferred:

• Master’s degree in Nursing
• 5+ years effectively writing clinical appeals and denial management
• 2+ years inpatient coding or coding denials management
• Active, current, and unrestricted ARNP or PA license
• Foreign trained medical graduate
• RN, ARNP, PA, or foreign medical graduate, plus CCS

Position will support Tenet corporate located in Texas. Tenet Healthcare complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.