Denials Management Specialist

🕒 3 dias atrás

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Pennant

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

Fundada em 2016

🏥 Saúde

⚕️ Seguro de Saúde

🧘 Bem-estar

Healthcare • Healthcare Insurance • Wellness

A Pennant é uma empresa dedicada a fornecer serviços de saúde, com foco em serviço transformador, cultura e liderança. Eles apoiam subsidiárias operacionais independentes que oferecem cuidados de saúde domiciliar, hospice, vida assistida, vida independente e cuidados de memória. Sua missão é capacitar líderes locais com recursos e ferramentas para oferecer cuidados de alta qualidade. A Pennant opera 103 agências de cuidados de saúde domiciliar e hospice e 51 comunidades de moradia para idosos em vários estados dos EUA, incluindo Arizona, Califórnia e Texas. Eles enfatizam uma forte cultura empresarial guiada por valores fundamentais que priorizam o atendimento ao cliente, responsabilidade e tomada de riscos inteligentes.

Descrição

• Perform comprehensive clinical and regulatory reviews of records submitted for payer, government, and external audit requests • Manage assigned audit reviews from intake through submission, including ADR, TPE, UPIC, SMRC, RAC, MAC, Medicaid, managed care, and other payer or regulatory reviews • Review medical records for completeness, accuracy, medical necessity, eligibility, certification/recertification support, plan of care compliance, visit documentation, orders, signatures, and payer-specific requirements • Apply Medicare, Medicaid, payer, hospice, home health, and internal review standards to evaluate claim defensibility • Identify documentation gaps, audit vulnerabilities, technical deficiencies, and recurring denial drivers • Prepare organized audit packets and review summaries for external reviewers, payers, and government contractors • Support appeal development by analyzing denied claims and summarizing clinical and regulatory support • Coordinate audit response activities with agencies, clinical operations, revenue cycle, finance, compliance, and legal teams • Recommend corrective actions, process improvements, and targeted education based on audit findings and risk trends • Maintain proficiency in audit review, tracking, reporting, and healthcare information systems

🎯 Requisitos

• Registered Nurse or other applicable clinical licensure strongly preferred • Equivalent clinical, audit, compliance, revenue cycle, or denials management experience may be considered based on business need • Minimum of five years of experience in home health, hospice, post-acute care, clinical documentation review, audit response, appeals, compliance, or denials management preferred • Strong working knowledge of Medicare, Medicaid, managed care, and payer documentation requirements • Knowledge of home health and hospice eligibility, medical necessity, certification, recertification, plan of care, orders, signatures, and visit documentation standards • Ability to interpret payer audit requests and identify required documentation • Ability to evaluate record completeness and organize submission packets accurately and timely • Ability to synthesize complex clinical, operational, and regulatory information into clear findings, recommendations, and education opportunities • Excellent written and verbal communication skills • Highly detail-oriented, deadline-driven, and able to prioritize competing assignments with minimal supervision • Comfortable working independently in a remote environment while collaborating with cross-functional partners • Proficiency with healthcare information systems, electronic medical records, Microsoft Office, Excel, PDF tools, Smartsheet, payer portals, and audit tracking or reporting platforms

🏖️ Benefícios

• CAPLICO culture focused on personal and professional development • Equal opportunity employment • Centralized Service Center support including clinical, legal, risk management, HR, training, accounting, and IT resources