✓You’ll need

Licensure

✓Current active unrestricted RN license.

Certifications

Healthcare Financial Management Association (HFMA) Certification Preferred.

CCDS or CDIP Certification Preferred.

Education

✓Associates Degree

Qualifications

✓3 years of relevant nursing experience

✓Knowledge and use of discharge planning, case management, utilization review, and levels of care criteria.

✓Familiarity with Medicaid and Medicare claims denials and appeals processing and regulatory requirements.

✓Knowledge and use of payer medical policy and Medicare LCD/NCD criteria.

✓Knowledge of billing and coding requirements.

✓Experience utilizing Milliman Care Guidelines and InterQual Criteria.

✓Knowledge of current NCQA/URAC standards.

✓Knowledge and experience applying 2-Midnight Rule Criteria.

✓Knowledge and experience in Epic.

✓Must have the ability to effectively utilize Microsoft Office Suite and possess basic data entry skills.

✓Must possess excellent verbal, written and interpersonal communication skills, and able to balance multiple demands and respond to time constraints.

✓Must have high-level skills in organization as well as problem solving and analytical skills.

✓This vacancy is not eligible for sponsorship / we will not sponsor or transfer visas for this position.

The preferred applicant will have the following experience: Advanced knowledge of ICD-10-CM/PCS coding conventions, DRG reimbursement methodology, and clinical validation principles, with demonstrated ability to interpret Coding Clinic guidance and Medicare IPPS regulations to support accurate DRG a

Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred.

+Benefits

Medical: Multiple plan optionsDental: Delta Dental or reimbursement account for flexible coverageVision: Affordable plan with national networkPre-Tax Savings: HSA and FSAs for eligible expenses

About the role

Primary duties may include, but are not limited to, responsibility for reviewing assigned clinically related denials, payer audits, and payer correspondence as well as preparation of relevant appeal submission or audit responses.

This is a hybrid position and must be located within 100 miles of any of the Mayo Clinic campuses for on-site expectations based on business needs. Primary duties may include, but are not limited to, responsibility for reviewing assigned clinically related denials, payer audits, and payer correspondence as well as preparation of relevant appeal submission or audit responses. Utilizes clinical expertise and critical thinking in the evaluation of medical records against appropriate criteria and contract requirements and utilizes appropriate communication style to appeal or defend medically denied claims.

Is a liaison and resource to revenue cycle, case management and practice stakeholders in defending clinically denied claims and providing relevant feedback to key stakeholders on denial prevention opportunities. Minimum

Associates Degree Minimum

3 years of relevant nursing experience Current active unrestricted RN license. The preferred applicant will have the following

Advanced knowledge of ICD-10-CM/PCS coding conventions, DRG reimbursement methodology, and clinical validation principles, with demonstrated ability to interpret Coding Clinic guidance and Medicare IPPS regulations to support accurate DRG assignment and defend coding-related denials. Healthcare Financial Management Association (HFMA) Certification Preferred. CCDS or CDIP Certification Preferred.

Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review, and levels of care criteria. Familiarity with Medicaid and Medicare claims denials and appeals processing and regulatory requirements.

Knowledge and use of payer medical policy and Medicare LCD/NCD criteria. Knowledge of billing and coding requirements. Experience utilizing Milliman Care Guidelines and InterQual Criteria.

Knowledge of current NCQA/URAC standards. Knowledge and experience applying 2-Midnight Rule Criteria. Knowledge and experience in Epic.

Must have the ability to effectively utilize Microsoft Office Suite and possess basic data entry skills. Must possess excellent verbal, written and interpersonal communication skills, and able to balance multiple demands and respond to time constraints. Must have high-level skills in organization as well as problem solving and analytical skills. **This vacancy is not eligible for sponsorship / we will not sponsor or transfer visas for this position.

Full time Benefits
Medical: Multiple plan options
Dental: Delta Dental or reimbursement account for flexible coverage
Vision: Affordable plan with national network
Pre-Tax Savings: HSA and FSAs for eligible expenses
Retirement: Competitive retirement package to secure your future

Clinical Appeals Specialist II-Hybrid

About the role