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Northwell Health · 1 day ago

Clinical Denials & Appeals Specialist

Melville, NY

Full-time

Onsite

Mid Level

$78K/yr - $130K/yr

Northwell Health is seeking a Clinical Denials & Appeals Specialist who will act as a resource for the Health System and address Corporate Compliance Audits. The role involves reviewing denial trends, preparing and defending cases for medical necessity, and ensuring compliance with regulations.

ConsultingHealth CareHealth DiagnosticsMedicalPublishing

Responsibilities

Serves as liaison between the patient and facility/physician and the third party payer

Prepares and defends level of care and medical necessity for assigned case

Collaborates with physician advisor, payor representative and site case managers to facilitate appropriate level of care decisions and billing status and ensures compliance with the Utilization Review standard and regulations

Performs concurrent and retrospective utilization management using evidenced-based medical necessity criteria; conducts clinical reviews and formulates appeal letters to support appropriateness of admission and continued length of stay

Ensures compliance with current state, federal, and third-party payer regulations

Ensures clinical reviews and appeals are up to date and accurately reflect patient’s severity of illness and intensity of services provided

Performs PRI’s (Patient Review Instrument), as needed

Performs related duties as required

Qualification

Registered Nurse LicenseNursing DegreeUtilization ManagementClinical ReviewsCommunication Skills

Required

Graduate from an accredited School of Nursing

Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed

Must be enrolled in an accredited BSN program within two (2) years and obtain a BSN Degree within five (5) years of job entry date

Preferred

Bachelor's Degree in Nursing, preferred

Company

Northwell Health

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Northwell Health is New York State’s largest health care provider and private employer, with 28 hospitals, about 1,000+ outpatient facilities and more than 16,000 affiliated physicians.

Founded in 1997