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Oracle · 1 month ago

Senior Claim Denial Prevention & Appeals Specialist

United States

Full-time

Remote

Mid, Senior Level

3+ years exp

Oracle is a leading enterprise software company focused on improving patient care through innovative solutions. The Senior Claims Denial Prevention and Appeals Specialist will be responsible for leveraging clinical expertise to manage claim denials and enhance reimbursement processes.

Data GovernanceData ManagementEnterprise SoftwareInformation TechnologySaaSSoftware

No H1B

Responsibilities

Provide clinical inputs to engineering for developing the Claim Denial Prevention and Appeals features of Oracle Health Clinical AI Agent (CAA)

Leverage expert clinical judgment and regulatory knowledge to lead the appeals initiative to review denied claims

Create write-ups for appeals packets

Identify trends/improvement opportunities to prevent future denials

Ensure maximum appropriate reimbursement

Qualification

Claim denial appealsAnalyzing claim denialsClinical validationMedical necessity knowledgeUtilization Review experienceHealthcare quality certificationCommunication skillsTeam collaboration

Required

3+ years hands on experience preparing appeals for claim denials in the hospital and ambulatory setting

3+ years hands on experience in analyzing claim denials and formulating strategies for preventing future denials

Background knowledge of HIM field helpful, with focus on different reimbursement methodologies, AHA coding guidelines, and Clinical Documentation Improvement experience

Knowledge of medical and insurance terminology, MS-DRG, APR-DRG, CPT, ICD coding structures, and billing forms (UB, 1500)

Experience with coding, clinical validation, and medical necessity for outpatient and inpatient stays

Knowledge of third-party payor rules and regulations