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Clinical Appeals Specialist, RN

Medical Billing / Coding

Job ID 24REQ-05293

About Xtend Healthcare
Xtend Healthcare is a revenue cycle management company focused exclusively on the healthcare industry. The company's services range from full revenue cycle outsourcing, A/R legacy cleanup and extended business office to coding and consulting engagements. As part of Navient (Nasdaq: NAVI), Xtend taps the strength and scale of a large-scale business processing solutions company. Learn more at www.xtendhealthcare.net

THIS IS A REMOTE (WORK FROM HOME) POSITION. (All work must be performed in the United States for this remote role.)

Xtend Healthcare is looking for aClinical Appeals Specialist, RN who will work collaboratively with Xtend project leaders and / or with clients on a consulting basis to assist healthcare providers.

JOB SUMMARY:

  • Evaluates, reports findings, and provides recommendations on denied or underpaid claims.

  • At the direction of Xtend Project leaders and based on instructions provided by the client (hospital and/or physician practice) assists to ensure services inappropriately denied by payers are identified, compliantly appealed and reversed.

  • Works closely with appropriate departments / functional areas of the client, e.g. Patient Care Management, HIM/coding and medical team, to review and obtain medical documentation required to facilitate denial appeals process.

  • Upon direction of the Xtend Project leader and with approval of the client, may work proactively within various medical multidisciplinary teams to develop procedures to reduce the number of denials received through reporting of denials and education of denial trends.

  • May be asked to compile, analyze and report on data related to underpayments, denials, revenue opportunities and revenue leakage.

  • If applicable, categorizes denials based on root cause findings and distributes reports and metrics to applicable Xtend leaders, client representatives and teams

  • Serves as a resource when needed for Xtend billing and reimbursement questions requiring clinical knowledge and / or medical records review and interpretation

  • Continuously reviews applicable regulations, updates and maintains current knowledge

  • Other duties as assigned related to clinical review and patient care management

1.  Clinical documentation review and evaluation.    

  • Assists Xtend Project leaders with identification of the reason (either technical or clinical) for denied services.

  • Understands whether provider documentation supports a clinical appeal.

  • Prepares appeal letter if appropriate.

2.  Project assistance related to outstanding facility coding and/or charge requests.             

  • Works proactively with Xtend Project leaders to improve communication regarding clinical information required for account resolution.

3. Direct assistance to client hospitals and/or physician practices.     

  • Client may need assistance with clinical decision-making process improvement and/or documentation improvement.

For example:  Patient status determination (IP, OP or OBS) Optimizing DRG categorization.

  • May assist with communication between Patient Care Management and Health Information Management to improve processes and coding.

For example:  Concurrent DRG assignment

4.  Client and/or Xtend Project Training            

  • As governmental regulations change, may provide training to client and/or Xtend team members in the areas of coverage of services, coding, billing and reimbursement based on clinical requirements.

  • May travel to a client location to provide training.

5.  Provide consulting services in the areas of patient care management – Case  Manager, utilization review nurse, discharge planner and/or documentation

Review Specialist.

6.  Since this is a new position for Xtend and Project / Client needs are still being assessed, this job role may include other duties as yet to be determined.

This position is also responsible for actively supporting the execution of specific project strategic initiatives, client process re-design, root cause analysis, metric/report development and special projects as it relates to clinic review and denials management.

MINIMUM REQUIREMENTS:

  • Bachelor's degree in Nursing, Business, Health Information, Clinical Studies, Registered Nurse (RN) from an accredited institution

  • Five (5) years’ experience as an RN. At a minimum, this must include utilization review experience.

  • Electronic health record (EHR) expertise, including knowledge of a variety of vendors

OFFICE AND TECHNOLOGY REQUIREMENTS:

Xtend Healthcare will provide all hardware and software.  Qualified candidates must secure the following to successfully execute job responsibilities:

  • ​Reliable high-speed internet– 100mbps download, 10 upload speed minimum, and latency less than 25 ms: (Please note: Rural, Satellite Services, MIFI/Jetpacks, 5G networks, Google Pod, EERO Device and WIFI extenders are not compatible with our systems)

  • Cell phone that has the ability to download an app

  • Wired internet connection by connecting an Ethernet cord into your server from the router/modem

  • Computer equipment will be provided on Day 1 of Training

  • Private workspace or home office free from distractions

  • As a work-from-home employee, I understand that I may encounter slowdowns during periods of heavy internet use due to a variety of factors; one of which is the number of devices connected to the internet in the home and especially devices streaming Netflix, Hulu, games etc. I understand that WiFi is not compatible with company systems and that connecting device directly to the router will provide the best connection.

PREFERRED QUALIFICATIONS:

  • Previous experience working denial/appeal management with appeal writing experience on both the provider and payor side.

  • Must be an RN, with clinical knowledge of documentation requirements for payment

  • Must have working knowledge of patient care management “best practices” and HIM coding guidelines

  • Must be able to interact positively with clients and understand their needs in the patient care arena.

  • Experience in managed care contracts, reconciling patient accounts, and balancing payment transactions against contract rates and terms is strongly desired

  • Collaborative work experience with a hospital Revenue Cycle department desired

  • Exercise understanding of hospital and professional services payer adjudication rules

  • Ability to read and interpret medical charts and related documentation

  • Experience in hospital operations and general understanding of revenue cycle with an emphasis on coverage, charge capture, coding, billing and reimbursement methodologies

  • Keen attention to detail with ability to spot trends and proactively reduce denials

  • Critical thinker with demonstrated ability to perform root cause analysis, problem solve, prepare and implement action plans and lead improvement initiatives

  • Strong oral and written communication skills

  • Excellent interpersonal skills and experience interacting with clinicians and financial personnel

  • Proficiency in the use of PCs and MS Office suite

  • Ability to adapt to a changing and dynamic environment

  • Comfortable working in both individual and team settings, and on-site with clients

  • Ability to interpret and implement regulatory standards

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