Clinical Appeals Specialist

Overview

Under the general supervision of the Director of Patient Financial Services, the Clinical Appeals Specialist performs advanced level work related to clinical denial management. The individual is responsible for managing medical denials by conducting a comprehensive review of relevant clinical documentation. The Clinical Appeals Specialist will write compelling arguments based on clinical documentation and payer medical policies and submit the appeal to the underlying payer in a timely manner. They work closely with representatives from third-party payers to research and resolve denials related to medical policy/medical necessity. Through an understanding of the healthcare environment and DFCI’s mission, the specialist serves as an informed clinical resource to support hospital billing compliance, post payment audit and other hospital functions and initiatives. The successful candidate will work independently, troubleshoot, problem solve and effectively communicate issues and potential solutions to management.

The selected candidate must live and work from one of the New England states (ME, NH, VT, MA, RI, CT)

Located in Boston and the surrounding communities, Dana-Farber Cancer Institute brings together world renowned clinicians, innovative researchers and dedicated professionals, allies in the common mission of conquering cancer, HIV/AIDS and related diseases. Combining extremely talented people with the best technologies in a genuinely positive environment, we provide compassionate and comprehensive care to patients of all ages; we conduct research that advances treatment; we educate tomorrow's physician/researchers; we reach out to underserved members of our community; and we work with amazing partners, including other Harvard Medical School-affiliated hospitals.

Responsibilities

PRIMARY DUTIES AND RESPONSIBILITIES:

• Review and research denials related to clinical or medical necessity issues to determine if an appeal is warranted.
• Formulate clinical appeals and letters of medical necessity to be sent to third-party payers for inpatient and outpatient services.
• Organize clinical information, formulate and submit clinical appeals to insurers.
• Maintain the clinical appeals database used for reporting and denial trending.
• Communicate with Hospital Billing Compliance Department to identify opportunities to improve and/or clarify documentation in the electronic medical record to support the medical necessity of patient care services.
• Participate in developing solutions for identified reimbursement issues related to payer medical policies and reimbursement guidelines.
• Track and trend all second level appeals to determine volume and categories of appeals, root cause, success rates and trends; including denials that have been escalated to the Medicare Administrative Law Judge (ALJ).
• Represent DFCI at ALJ hearings for Medicare denials.
• Serve as a resource to other departments both within and outside DFCI to prepare appeals, respond to audits and support DFCI initiatives.
• Document key business process workflows, policies and procedures.
• Adhere to HIPAA and confidentiality guidelines.

Qualifications

MINIMUM JOB QUALIFICATIONS:

• Bachelor’s degree in nursing or related medical field.
• 5 years case management experience in an acute care setting and/or experience in insurance-based utilization review, clinical prior authorization review and preparing and managing clinical appeals.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:

• Knowledge of third-party payer rules and regulations.
• Broad knowledge of health care business office practices and principles.
• Intermediate to advanced proficiency in Microsoft Word, Excel, Access and PowerPoint.
• Superior written and verbal communications skills used to effectively work and communicate with all levels of internal and external staff (e.g., managers, physicians, clinical and support staff).
• Strong problem-solving skills.
• Ability to react to frequent changes in duties and volume of work.
• Ability to maintain a strong relationship with medical staff and work collaboratively to positively affect clinical and financial outcomes.
• Ability to manage multiple tasks with ease and efficiency.
• Ability to work independently and be results oriented.
• Ability to work closely and effectively with peers across the organization.
• Commitment to a customer service philosophy.

Dana-Farber Cancer Institute, we work every day to create an innovative, caring, and inclusive environment where every patient, family, and staff member feels they belong. As relentless as we are in our mission to reduce the burden of cancer for all, we are equally committed to diversifying our faculty and staff. Cancer knows no boundaries and when it comes to hiring the most dedicated and diverse professionals, neither do we. If working in this kind of organization inspires you, we encourage you to apply.

Dana-Farber Cancer Institute is an equal opportunity employer and affirms the right of every qualified applicant to receive consideration for employment without regard to race, color, religion, sex, gender identity or expression, national origin, sexual orientation, genetic information, disability, age, ancestry, military service, protected veteran status, or other characteristics protected by law.