Nurse Specialist – Clinical Denials and Appeals

🔥 0 minutes ago

🌽 Illinois – Remote

🌽 Illinois – Remote

💵 $33 - $43 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Huron

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 2002

🤝 B2B

🏢 Enterprise

💸 Finance

B2B • Enterprise • Finance

Huron Consulting Group is a global consultancy that provides a wide range of services including strategy, operations, advisory, digital, technology, and analytics solutions to various sectors such as healthcare, education, energy, and financial services. Huron helps organizations navigate complex challenges and drive growth through tailored solutions and innovative strategies. The company employs a team of experts dedicated to delivering high-impact solutions that address the unique needs of each client, focusing on areas such as managed services, outsourcing, and leadership development.

📋 Description

• Responsible for reviewing the claims denied and carrying out the appeals process appropriately and in a timely manner • Identifies and works denials, responding to the denial reason and resubmitting any information needed to the payor • Work denials and appeals timely, evaluating the denial reason including information from the payor and payor policies, reviewing the clinical documentation, assessing options and completing next steps • Submit retro-authorizations in accordance with payor requirements in response to authorization denials • Conducts medical necessity reviews, based on denial root cause, and prepares any required clinical documentation summaries to accompany appeals. • Write and submit written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language • Document all actions taken and follow-up timely as needed related to resolving denials and appeals with third-party payers in a timely manner • Completes relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms • Complies with state and federal regulations, accreditation/compliance requirements, and Huron’s policies, including those regarding fraud and abuse, confidentiality, and HIPAA

🎯 Requirements

• At least 1 year of clinical appeal writing experience • Minimum of 3-5 years acute care clinical experience in a hospital setting (Med/Surg, or similar preferred); 2-3 years if ICU experience • Associate Degree in Nursing (ADN) or Diploma in Nursing • Must be Registered Nurse with an active USRN license • Proficiency in using InterQual or MCG clinical guidelines • Broad Knowledge of U.S. Government Programs and Insurance Regulations • Proficiency with hospital-based electronic medical records (EMR) such as Epic, Cerner, or Meditech • Case management or clinical appeals or clinical denials certification (ACMA) is preferred. • Proficiency with Microsoft office suite (Excel, Word, PowerPoint, Outlook, SharePoint)

🏖️ Benefits

• Medical, dental and vision coverage • Employee stock purchase plan • 401(k) plan with a generous employer match • Paid Time Off policy • Paid parental leave and adoption assistance • Free annual health screenings and coaching