Clinical Denials Analyst (RN)
Altru Health

Job Info

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Location:
Altru Health System

PO Box 6002Grand Forks, ND 58201

Pay Range: $60,715.20 - $91,083.20

Summary:
The Clinical Denials Analyst serves as a resource in daily, monthly and yearly operations, with preparing projections, participating in the development and implementation of policies, procedures and goals related to claim denials. The individual is responsible for researching, managing, maintaining, and communicating denial/appeal activity to appropriate stakeholders and Revenue Cycle Management. The Clinical Denials Analyst conducts comprehensive reviews of the claim denial, account/guarantor notes, and the medical record to determine if or any further action needs to be made on a claim. The Clinical Denials Analyst will work closely with Clinical Pre-Authorization Representative to review claims for medical necessity, appropriateness and to escalate to the Medical Director when necessary.

Essential Job Functions:

• Manages and researches claim denials related to referral, authorizations, notifications, non-coverage, medical necessity, and others as assigned.
  
• Conducts comprehensive reviews of denials and medical records to make determinations and recommendations to managers, supervisors and key stakeholders on a regular schedule for work flow improvement.
  
• Tracks denials by third party payers and PPO networks to determine discrepancies with AHS patient access and billing systems.
  
• Participates in financial system development, analysis, maintenance, and reporting.
  
• Develops strong working interdepartmental relationships with leaders throughout Altru for work-flow improvement based on denial analysis.
  
• Partners with Payer Enrollment ensuring provider/location are enrolled correctly with the payers.
  
• Assists the Manager/Supervisor in defining new requirements, suggesting solutions and testing additional systems for enhancements.
  
• Identifies delays, inefficiencies and errors which hinder the claim process and make recommendation for additions/revisions/deletions to work queues and claim edits to improve efficiency and reduce denials.
  
• Demonstrates knowledge of the Managed Care Information Systems programs for pre and prior authorization and eligibility purposes, knowledge of state/federal benefits, coverage mandates and related process requirements
  
• Performs other duties as assigned or needed to meet the needs of the department/organization.
  

Certifications

• Registered Nurse | North Dakota Board of Nursing (NDBON) or Compact State Agreement | Prior to Start Date | HR Primary Sources
  
• Registered Nurse | Minnesota Board of Nursing | Prior to Start Date | HR Primary Sources
  

Education:

• Required: Associates - Nursing
• Preferred: Bachelors - Nursing

Work Experience:

• Preferred: A minimum of 3 years Related Experience

Physical Demands :

• Sit: Frequently (34-66%)
• Stand: Occasionally (5-33%)
• Walk: Occasionally (5-33%)
• Stoop/Bend: Occasionally (5-33%)
• Reach: Frequently (34-66%)
• Crawl: Not Applicable
• Squat/Crouch/Kneel: Rarely (1-4%)
• Twist: Occasionally (5-33%)
• Handle/Finger/Feel: Continuously (67-100%)
• See: Continuously (67-100%)
• Hear: Continuously (67-100%)

Weight Demands:

• Lift -Floor to Waist Level: Sedentary (< 10 pounds)
• Carry: Sedentary (< 10 pounds)
• Push/Pull: Sedentary (< 10 pounds)
• Slide/Transfer: Not Applicable

Working Conditions:

• Indoor: Continuously (67-100%)
• Outdoor: Not Applicable
• Extreme Temperature: Not Applicable

Driving Requirement Definitions:

• Professional Drivers: Persons who drive as their main responsibility OR transport passengers or hazardous materials.
• Frequent Drivers: Persons whose main responsibility is not driving, but drive daily or almost daily.
• Occasional Drivers: Persons who drive from once per month to as frequently as once per week.
• Infrequent Drivers: Persons who are generally not expected to drive.

Driving Requirement for this position:
Infrequent Driver

Reference ID: R4764

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