Clinical Denials Program Coordinator

Compliance with payer, state, and federal regulations and policies is critical to the financial health of a health care organization. The Coordinator, Clinical Denials program works within the Utilization and Patient Financial teams to maximize reimbursement and compensation while assisting the organization to remain compliant with regulations and policies. Daily activities include addressing authorization and payment issues following patient discharge: appeals of payment denials and leading activities concerning certain QIO matters, and CMS regulations. Requirements: •Graduate of an accredited school of nursing required. •Bachelor’s degree preferred. •Current RN license in the state of Illinois required. •2 years of case management or related experience required. •Comprehensive knowledge of Regulatory guidelines for Medicare, Medicaid, and, other Federal or State reimbursement programs required. •Understanding of CMS Conditions of Participation. •Commercial payor contracts and healthcare reimbursement law and ethics to support organizational compliance with regulation while maximizing reimbursement •Statistics and meaning of data to support communication of appeals, denials, and utilization processes •Proficient in Microsoft Office Word, Excel, and Outlook required. •Knowledgeable in using electronic medical records. •Meticulous attention to detail •Strong organizational skills •Data base management

Compliance with payer, state, and federal regulations and policies is critical to the financial health of a health care organization.  The Coordinator, Clinical Denials program works within the Utilization and Patient Financial teams to maximize reimbursement and compensation while assisting the organization to remain compliant with regulations and policies.  Daily activities include addressing authorization and payment issues following patient discharge:  appeals of payment denials and leading activities concerning certain QIO matters, and CMS regulations. 

Requirements:

  • Graduate of an accredited school of nursing required.

  • Bachelor’s degree preferred.

  • Current RN license in the state of Illinois required.

  • 2 years of case management or related experience required.

  • Comprehensive knowledge of Regulatory guidelines for Medicare, Medicaid, and, other Federal or State reimbursement programs required.

  • Understanding of CMS Conditions of Participation.

  • Commercial payor contracts and healthcare reimbursement law and ethics to support organizational compliance with regulation while maximizing reimbursement

  • Statistics and meaning of data to support communication of appeals, denials, and utilization processes

  • Proficient in Microsoft Office Word, Excel, and Outlook required. 

  • Knowledgeable in using electronic medical records.

  • Meticulous attention to detail

  • Strong organizational skills

  • Data base management

We provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.