RN - Clinical Denial Management
Posted on: August 7, 2022
The Clinical Denial Management - RN participates in clinical
review and development of well-constructed appeal arguments for
reconsideration of medical services that may have been denied.
Denial of payment may be based on insufficient clinical
documentation to support the level of care, utilization review,
determination that a treatment is investigational/experimental,
and/or that the treatment rendered is not medically necessary.
- The Clinical Denial Management - RN will review the case, and
determine the potential for an appeal on a denied claim.
- Create quality appeal letters to achieve maximum overturn rate.
The appeal letter will be written in an objective narrative form,
utilizing appropriate formatting, appropriate English grammar,
based on current evidenced based criteria, medical literature if
applicable, healthcare statutes, and clinical judgment.
- Stays abreast of regulatory changes and payer policies.
- Utilizes evidenced based criteria and other resources to
develop sound and well-supported appeal arguments.
- Performs duties in accordance with the ethical and legal
compliance standards as set by Carle Health, and all regulatory
agencies, including State and Federal.
- Maintains strictest confidentiality of protected health
information (PHI) in accordance with the Health Insurance
Portability and Accountability Act (HIPAA).
- Focuses on the review and analysis of governmental denial
rationales and provides appropriate medical necessity appeal
- Review governmental contractors response letter in comparison
to the medical records.
- Researches medical literature and evidence based medical
publications to support the level of care provided.
- Reviews/audits medical necessity denials looking for patterns
by services or by the physician.
- Works with leadership to improve clinical documentation,
understand root causes, and to reduce denials.
- Works collaboratively with health information management coding
staff, physicians and financial services to resolve payment denials
and clinical documentation issues.
- Adept at working in a fast paced, collaborative environment
with multi-disciplinary teams across the institution.
- Ensures quality and productivity standards are met or
- Functions effectively within a team and participates and
contributes constructively to produce results in a cooperative
- Ensure workload is completed in an efficient and timely
- Participates in projects as needed.
Keywords: CARLE, Champaign , RN - Clinical Denial Management, Healthcare , Urbana, Illinois
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