Clinical Denials Auditor

The Clinical Denials and Appeals Nurse Specialist (IP & OP) is responsible for reviewing denied claims and carrying out appeals processes appropriately and in a timely manner. The Specialist identifies and works on denials, responding to the denial reason and resubmitting any information needed to the payor. The role requires knowledge of U.S. state/federal laws related to payor contracts and the appeals process, frequent and effective communication via phone, email, and instant messaging with engagement teams, strong oral and written communication skills, analytical skills, and the ability to work independently and be self‑motivated.

KEY RESPONSIBILITIES

Denials and Appeals Management 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. Conduct medical necessity reviews based on denial root cause and prepare 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. Appeals are submitted timely and tracked through final outcome. Document all actions taken and follow up timely as needed related to resolving denials and appeals with third‑party payers in a timely manner. Track the status and progress of denials and appeals. Complete relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms. Execute internal and external correspondence accurately, clearly, concisely, and professionally while following organizational regulations. Effectively handle all communications, including telephone, electronic, and paper correspondence from payers and departments within the business office. Tracking, Reporting, and Trends Maintain data on the types of claims denied and root causes of denials. Identify denial patterns and escalate to management as appropriate with sufficient information for additional follow‑up and/or root cause resolution. Collaborate with management to recommend process changes to address root cause of denials and overall improvement to reduce A/R. Prepare, maintain, assist with, and submit reports as required. Compliance and Continuous Improvement Collaborate with team members to continually improve services and engage in process and quality improvement activities. Identify system improvement opportunities and contribute to the testing of system modifications. Conduct relevant research to assist with completing the appeals process and to stay informed on best practices and policy reforms. Comply with state and federal regulations, accreditation/compliance requirements, and Huron’s policies, including those regarding fraud and abuse, confidentiality, and HIPAA. Maintain a thorough understanding of federal and state regulations, as well as specific payer requirements and explanations of benefits, in order to identify and report billing compliance issues and payer discrepancies. Participate in ongoing professional development to enhance job knowledge and performance. Report all identified compliance risks to appropriate leadership. Other duties and responsibilities as assigned. Required Qualifications Clinical appeals experience: At least 1 year of clinical appeal writing experience. Clinical 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. Education: Bachelor of Science in Nursing. Licensure: Must be a Registered Nurse with an active USRN license. RCM knowledge: Proficiency in using InterQual or MCG clinical guidelines. Broad knowledge of U.S. Government Programs and Insurance Regulations. Software knowledge: Proficiency with hospital‑based electronic medical records (EMR) such as Epic, Cerner, or Meditech. Preferred Qualifications Education: Master’s degree or credential in business, healthcare, or related field preferred. Credential/Certification: Case management or clinical appeals or clinical denials certification (ACMA) is preferred. Software knowledge: Proficiency with using computer programs for tracking denials and appeals. Proficiency with Microsoft Office Suite (Excel, Word, PowerPoint, Outlook, SharePoint). Soft skills: Ability to pay close attention to details; strong follow‑up and follow‑through skills. Regularly make complex decisions within the scope of the position and be comfortable working independently. Use independent judgment, discretion, and decision‑making abilities. Demonstrate teamwork and integrity in all work‑related activities. Ability to interact with internal and external customers in a professional manner. Strong analytical and critical thinking skills. Experience in a matrixed environment. Excellent written and verbal communication skills. Position Level Analyst Country United States of America Estimated hourly range $33.65 – $43.27 Benefits Huron offers a competitive compensation and benefits package including medical, dental, and vision coverage to employees and dependents; a 401(k) plan with a generous employer match; an employee stock purchase plan; a generous Paid Time Off policy; and paid parental leave and adoption assistance. Our Wellness Program supports employee total well‑being by providing free annual health screenings and coaching, bank at work, and on‑site workshops, as well as ongoing programs recognizing major events in the lives of our employees throughout the year. All benefits and programs are subject to applicable eligibility requirements. Equal Employment Opportunity Statement Huron is fully committed to providing equal employment opportunity to job applicants and employees in recruitment, hiring, employment, compensation, benefits, promotions, transfers, training, and all other terms and conditions of employment. Huron will not discriminate on the basis of age, race, color, gender, marital status, sexual orientation, gender identity, pregnancy, national origin, religion, veteran status, physical or mental disability, genetic information, creed, citizenship or any other status protected by laws or regulations in the locations where we do business. We endeavor to maintain a drug‑free workplace. #J-18808-Ljbffr Huron Consulting Group