Clinical Documentation Specialist
Clinical Documentation Specialist
RN or LPN
Summary:
In this role, you will play a crucial part in reviewing and responding to commercial and governmental payer audit activity. Your primary focus will be on resolving audit requests promptly and accurately.
ESSENTIAL DUTIES AND
Responsibilities:
Identifying the root cause of clinical claim denials.
Utilizing clinical decision-making skills to determine the appropriate actions required to recover or defend revenue.
Crafting professional appeals in response to denied claims or payer audit requests.
Participating in live conferences and appeal hearings, as needed.
Identifying and reporting trends to remediate issues and support internal process improvement.
Engaging in relevant team calls and meetings.
Tracking and maintaining an appeal log.
Collaborating closely with Accounts Receivable and Case Management to ensure claims are paid appropriately and in a timely manner.
Performing other tasks and duties as assigned.
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below are representative of the knowledge, skill, and/or ability required.
Active RN or LPN license.
Minimum of 2 years of experience in audit and appeals processing (long-term care experience preferred).
Understanding of the Revenue Cycle, including admission, billing, payments, and denials (preferred).
Knowledge of additional documentation requests, Target Probe and Educate audits, and skilled level of care, basic principles.
Familiarity with payor medical necessity guidelines.
Ability to analyze medical records documentation and apply criteria and guidelines effectively.
Strong written and verbal communication skills, with the ability to read, interpret, and present information clearly and informatively.
Effective interpersonal skills, including the ability to communicate persuasively and respond well to questions and feedback.
Strong organizational, communication, and interpersonal skills.
Demonstrated ability to exercise judgment in interpreting results and communicating appropriate courses of action.
Self-motivated with the ability to work independently, exercise sound judgment, pay attention to detail, and maintain a positive attitude.
Understanding of the importance of maintaining confidentiality of all medical, financial, and legal information.
Ability to complete work assignments accurately and in a timely manner.
Proficiency in Microsoft Office applications.
Please note that the responsibilities and requirements outlined in this job description are not exhaustive and may be subject to change or modification as deemed necessary by the organization.
PHYSICAL DEMANDS:
The physical demands are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Must be able to move intermittently throughout the workday.
Must be able to lift, push, or pull a minimum of 25 lbs.
Estimated Salary: $20 to $28 per hour based on qualifications.
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