CLINICAL APPEALS SPECIALIST, Multistate

Working at Moffitt is both a career and a mission: to contribute to the prevention and cure of cancer.
As the only National Cancer Institute-designated Comprehensive Cancer Center based in Florida, Moffitt employs some of the best and brightest minds from around the world. Join a dedicated team of nearly 10,000 who are shaping the future we envision.
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A National Cancer Institute (NCI)-designated Comprehensive Cancer Center since 2001.

Summary

Moffitt Cancer Center in Tampa, FL is recruiting for Clinical Appeals Specialist . For Florida residents and other select states (AL, AZ, AR, FL, GA, ID, IN, IA, KS, LA, MS, MO, MT, NC, OH, OK, SC, SD, TN, TX, UT, VA, WY) this full-time remote position offers a remote work arrangementPosition Highlights:

Responsible for the administration and coordination of the denials review and appeals management processes that includes denials management, claims recovery, and denial root cause analysis.

The Ideal Candidate:

• Experience in oncology nursing, utilization review, quality management, and/or recent case management and Soarian experience.

Responsibilities:

• Submit medical necessity appeals electronically and/or mail. Follow up electronically and/or telephonically with payers for claim and appeal status.
• Make a preliminary determination whether denial can be overturned and if initial or secondary appeals should be submitted.
• Research and prepare appeal responses to clinical denials.
• Review of clinical denials including identification of root cause.
• Resolve clinical denials which include researching and reviewing payer guidelines, writing and submitting appeals with supporting documentation if required.
• Identifies coding, billing, or reimbursement errors/discrepancies with the denial or aging claim in order to escalate to the denial recovery supervisor.
• Evaluate denied dollars for both contracting and non-contracting insurance companies; and resolution of reimbursement discrepancies.
• Resolution of denials for medical necessity, utilization review, pre-certification, authorization, and concurrent review to include writing appeals and responsible for conducting and preparing responses.
• Track and trend denials issues for escalation to leadership for process improvement.

Credentials and Qualifications:

• Bachelors Degree plus a minimum of five (5) years healthcare experience and RN required
• (OR) “in lieu of” a Bachelor’s degree you must have an Associates degree plus a seven (7) years healthcare experience preferably in Nursing and RN required.

**Accommodation: LPN’s currently in the role of Clinical Denial Specialist will be given a specified time frame (2 years) to obtain the RN licensure * “in lieu of” Associate’s, a H.S. Diploma with two (2) years of additional related claims/collection experience maybe considered.