Denials Prevention Specialist

Requisition ID

2020-14658

# of Openings

2

Category (Portal Searching)

HIM/Interim Solutions

Overview

The purpose of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of admissions for medical necessity and necessity of continued stay in the inpatient patient care setting and/or discharge to an alternative level of care. Using nationally recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully.

PRN: Flexible Schedule
- Benefits: 401k Savings Plan
- Location: This role will be performed at one location (Remote/WFH)
- Additional Details: Occassional travel may be required.

Responsibilities

- Responsible for providing timely referral/appeal determination by accurate
- Usage of the Milliman Care Guidelines and or Interqual
- Appropriate letter language to author appeal letter Identification of referrals to the medical director for review
- Appropriate selection of preferred and contracted providers
- Proper identification of eligibility and healthcare plans
- Maintaining compliance in turnaround time requirements as mandated by the TAT Standards of the facility and/or CIOX Health Standards
- Works directly with the provider(s) and health plan Medical Director as needed to facilitate timely authorizations and/or denial reversals
- Maintains and keeps in total confidence, all files, documents and records
- Meets or exceeds production and quality metrics
- Attend all mandatory meetings and trainings All other job-related duties as it relates to job function as delegated by management

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. List below is representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions
- Two (2) years managed care experience in UM/CM/CDI Department preferred
- Knowledge of CMS, State Regulations, URAC and NCQA preferred
- ICD10 and CPT coding a plus
- Experienced computer skills, Word, Excel, Outlook, experience working in a health plan medical management documentation system a plus.
Minimum Education: LVN/LPN
- Preferred Education: BA or BS in Nursing, experience preferred to preform
- Minimum Experience: 3 to 5 years acute care experience
- 2 years Health Plan or Acute Care UR/CM
- Preferred Experience: 5 years acute care or health plan UR/CM with 1 year ICU/ER

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Ciox provides equal employment opportunities to all associates and applicants for employment without regard to as race, color, national origin, genetic information, religion or religious creed, sex (including pregnancy, childbirth and related medical conditions), gender, gender identity, gender expression, sexual orientation, age, marital status, physical or mental disability, citizenship status, ancestry, military and veteran status, or any other characteristic as protected by state or federal law. Equal employment opportunity applies to all terms and conditions of employment, including hiring, placement, promotion, termination, layoff, recall, transfer, leave of absence, compensation, benefits, leaves of absence, and training.