Clinical Denial Analyst

RN Denial Analyst

Larkin Health System is an integrated healthcare delivery system accredited by the Joint Commission with locations in South Miami, Hialeah and Hollywood, Florida. Our network of acute care hospitals provide a complete continuum of healthcare services, including a full range of inpatient and outpatient services, and home health agencies in Miami-Dade and Broward County. We are heavily invested in training the next generation of health professionals, which is the core of our mission: to provide access to compassionate care of the highest quality in an educational environment.

The RN Denial Analyst is responsible for reviewing denial claims, submitting reconsiderations or appeals. Reporting to the Revenue Cycle Director, this role is responsible to optimize the financial outcomes of the hospital-based revenue cycle through maintaining a low denial rate and high reimbursement rate. Initiates a root cause analysis of denied payment through comprehensive means including but not limited to: research of patient stays and treatment, review of payer contracts, analysis of historical denials, appeals and their outcomes, emerging trends in payer practices and requirements. The RN denial analyst is considered an expert in denial management and ensures all denied claims are accurately worked from a technical/ billing perspective. Working in collaboration with the different revenue cycle departments through the health system to establish best practice solutions to maximize reimbursement and minimize organizational write-offs.

Duties and Responsibilities

• Tracks and analyzes denial data to identify, recommend, and implement opportunities to secure legitimate revenue for the organization. Identifies trends or patterns that impact payment optimization, and collaborates with departments to establish action plans, initiatives, and policies to reverse negative denial patterns.
• Prepare and defend level of care and medical necessity appeals.
• Generates, and audits various revenue, financial, statistical and/or quality reports surrounding the denial prevention area of focus.
• Supporting claims denials reductions and increased revenues through process redesign, root cause analysis and development of metric reports.
• Analyzes and reviews third party payer denial of medical claims and develops and executes strategies to decrease denials system wide to optimize revenue.
• Identifies revenue opportunities and provides appropriate investigation, follow up and resolution. Implements plans and partners with Managed Care Contracting to ensure proper adherence to contracts that does not affect revenue generation.
• Prepares clear and concise data reports to for senior leadership and others as required.

Qualifications for the Job

Education:

Registered nurse (RN), or Bachelor's degree in nursing or equivalent knowledge.

Experience :

• Three or more year's denials management, appeals, clinical documentation experience.
• Prior experience in claims processing and/or billing and collections.