Clinical Appeals Specialist - Registered Nurse

We are new but mighty. Xtensys, a recently established managed service provider, delivers cutting-edge technology to health systems, starting in NY and expanding beyond. Owned by two industry leaders focused on innovation in rural and community health, we are rapidly growing with several major initiatives underway. We seek a skilled RN Clinical Appeals Specialist to join our team of 500 and support our exciting journey. We value people and are building a culture to match. If you're a collaborative, innovative, and self-directed, we’d love to talk.

The RN Clinical Appeals Specialist is a vital member of the Revenue Cycle team, focusing on the administration and coordination of denial reviews and appeal management. RN Clinical Appeals Specialist works as an integral part of the Revenue Cycle team. Responsible for you will be responsible for reviewing and managing clinical denials, including determining whether denials can be recovered and identifying the need for additional appeal submissions. You will play a key role in the resolution of denied claims and work closely with leadership to improve denial management processes.

Preliminary Denial Assessment: Make a preliminary determination on whether clinical denials can be recovered and identify the need for additional appeal level submissions. Research & Appeal Preparation: Research clinical denials and prepare comprehensive appeal files in response, ensuring that all necessary documentation is included for review. Denial Analysis: Perform indepth analysis of clinical denials to identify root causes, ensuring that all contributing factors are addressed for successful resolution. Medical Necessity Review: Address denials that require medical necessity reviews, including writing appeals and preparing responses. Appeals & Documentation: Resolve clinical denials by researching and reviewing payer guidelines, and writing and submitting appeals with supporting documentation when necessary. Error Identification: Identify any coding, billing, or reimbursement errors/discrepancies related to denials or aging claims and escalate these issues to the Director of Denials for further action. Financial Analysis: Evaluate denied dollars against expected reimbursement to identify discrepancies and ensure proper financial resolution. Tracking & Trending: Track and trend denial issues, escalating significant cases to leadership to support process improvement initiatives. Special Projects: Participate in special projects as assigned to improve the efficiency of the denial resolution process and overall department performance.