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Premier Health Partners · 2 days ago

DENIAL MGMT CLINICAL ANALYST

Dayton, OH

Full-time

Onsite

Mid Level

3+ years exp

Premier Health Partners is seeking a Denials Management Clinical Analyst (DMCA) who is a registered professional nurse with expertise in process analysis and clinical outcome data analysis. The DMCA will work collaboratively with various teams to resolve third party payor denials, identify denial trends, and support clinical and financial integration across the care management team.

CommunitiesHealth CareHospitalMedicalPersonal Health

H1B Sponsor Likely

Responsibilities

Responds positively to, and adapts to, department and organizational changes

Knowledgeable of relevant state and federal laws/statutes/regulations pertaining to utilization, quality or reimbursement, and how those impact care at the point of service

Knowledge of clinical practice guidelines and appropriateness of clinical interventions

Performs medical record review, abstracting, aggregating, analyzing, interpreting and reporting complex clinical data obtained from the record

Compares data form the inpatient records to established criteria, determining legitimacy of admission, treatment, status, and length of stay

Prepares organized, clear, concise, accurate and informative written correspondence to the payer, analyzing the specified issues and clearly outlining the organization’s expectations

Accurately tracks in denials system actions taken to resolve denials and outcomes of those actions

Identifies clinical documentation, quality or legal issues and communicates those issues to the department leadership

Communicates clearly and collaborates effectively with internal and external customers

Utilizes facts, negotiation skills, persuasive abilities, adaptability and flexibility in resolving issues with internal and external customers

Has knowledge of 3rd party payer contracts, their terms, and how these impact point of service

Utilizes critical thinking skills in the identification of denials, analysis of denials, resolution of denials, and prevention of denials

Performs calculations to determine expected reimbursement, identify contractual adjustments, and evaluate the application of contract terms

Manage projects assigned by department leadership

Defines opportunities to improve denials management processes and department performance

Qualification

Registered NurseUtilization ManagementClinical Outcome Data AnalysisThird Party Payer KnowledgeProcess AnalysisMedicareMedicaid GuidelinesDenial ManagementMicrosoft ExcelMicrosoft WordAssertive CommunicationInterpersonal SkillsConflict Resolution SkillsCritical ThinkingProject Management

Required

Registered professional nurse with knowledge and expertise in process analysis, clinical outcome data analysis, utilization management, and utilization of information systems

Knowledgeable regarding changes in care delivery and their impact on third party reimbursement

Clinical expertise either as generalist or with a specific patient population

Support clinical and financial integration across the continuum and the care management team

Collaborate with Managed Care contracting staff, revenue cycle staff, Center for Status Integrity (CSI) team members, and other internal and external customers

Responsible for resolving third party payor denials and identifying denial trends by payer

Knowledgeable of third party payer contracts, Medicare and Medicaid guidelines, and other regulations which impact the utilization or denial of provider services

Respond positively to, and adapt to, department and organizational changes

Knowledgeable of relevant state and federal laws/statutes/regulations pertaining to utilization, quality or reimbursement, and how those impact care at the point of service

Knowledge of clinical practice guidelines and appropriateness of clinical interventions

Perform medical record review, abstracting, aggregating, analyzing, interpreting and reporting complex clinical data obtained from the record

Compare data from the inpatient records to established criteria, determining legitimacy of admission, treatment, status, and length of stay

Prepare organized, clear, concise, accurate and informative written correspondence to the payer, analyzing the specified issues and clearly outlining the organization's expectations

Accurately track in denials system actions taken to resolve denials and outcomes of those actions

Identify clinical documentation, quality or legal issues and communicate those issues to the department leadership

Communicate clearly and collaborate effectively with internal and external customers

Utilize facts, negotiation skills, persuasive abilities, adaptability and flexibility in resolving issues with internal and external customers

Knowledge of 3rd party payer contracts, their terms, and how these impact point of service

Utilize critical thinking skills in the identification of denials, analysis of denials, resolution of denials, and prevention of denials

Perform calculations to determine expected reimbursement, identify contractual adjustments, and evaluate the application of contract terms

Manage projects assigned by department leadership

Define opportunities to improve denials management processes and department performance

Bachelor's degree in Nursing

Registered nurse with valid Ohio license

3-5 years of job related experience

Prior job title or occupational experience in Case Management, Utilization Review

Personal computer skills required, including use of Microsoft Word, Microsoft Excel, EPIC

Experience in gathering information, monitoring indicators, and feedback mechanisms

Strong Interpersonal Skills

Ability to research, evaluate information, analyze problems and make appropriate recommendations

Demonstrated Conflict Resolution Skills

Assertive communication skills

Preferred

Certification in area of clinical specialty

Knowledge of hospital reimbursement, third party billing, government rules and regulations

Knowledge of InterQual and MCG, performance improvement, Medicare rules and regulations

Company

Premier Health Partners

Glassdoor3.4

Premier Health Partners is a partner of Catholic Health Initiatives at their Good Samaritan facilities.

Founded in 1995

Columbia, South Carolina, USA

10001+ employees

http://www.premierhealth.com

H1B Sponsorship

Premier Health Partners has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (1)

2024 (2)

2023 (1)

2022 (1)