· Responsible for the administration and coordination of the denials review and appeals management processes that includes denials management, claims recovery, and recovery audit contractor reviews.
The Ideal Candidate Will Have,
- Preferred – Experience in oncology nursing, utilization review, quality management, and/or recent case management Soarian experience.
- Submit appeals electronically and/or mail. Follow up electronically and/or telephonically with payers for claim and appeal status.
- Make a preliminary determination whether denial can be overturned and if initial or secondary appeals should be submitted.
- Research and prepare responses for payer requests for additional information and documentation.
- Review of clinical denials including identification of root cause.
- Resolve clinical denials which include researching and reviewing payer guidelines, writing and submitting appeals with supporting documentation if required.
- Identifies coding, billing, or reimbursement errors/discrepancies with the denial or aging claim in order to escalate to the denial recovery supervisor.
- Denied dollars for both contracting and non-contracting insurance companies; and resolution of reimbursement discrepancies.
- Resolution of denials for medical necessity, utilization review, pre-certification, authorization, and concurrent review to include writing appeals and responsible for conducting and preparing responses.
- Prepares responses to Medicare recovery audits (RAC) reviews received by Moffitt Cancer Center from any government entity.
- Claims Recovery
- Provides Appeals/Denials Consulting and Support.
- Other duties including special projects as assigned.
Credentials and Qualifications:
· Bachelor's Degree required.
· Registered Nursing (RN) license required.
· A minimum of five (5) years healthcare experience required.
** “in lieu of" a RN license, a Licensed Practical Nursing (LPN) license with an additional two (2) years in a nursing role experience with a total of seven (7) years may be considered.
** “in lieu of" a Bachelor’s degree you must have an Associate’s degree plus an additional two (2) years for a total of seven (7) years of healthcare experience - preferably in Nursing.