United Health Services
Clinical Denials Specialist
United Health Services, Binghamton, New York, United States, 13903
Job Responsibilities:
Prepare and submit timely, well‐documented appeals for denied services to Medicare, Medicaid, and commercial payers, including Insurance Reviewers, Hearing Officers, and Administrative Law Judges.
Track and evaluate denial patterns to identify root causes and collaborate with internal teams to implement strategies that reduce future denials.
Work with providers and hospital departments to ensure services are billed under the correct admission status and that documentation supports billing requirements.
Partner with physician and hospital coders to ensure accurate CPT coding for emergency Medicare admissions and support correct hospitalization status determinations.
Collaborate with insurance verification staff to resolve authorization issues and address denials related to coverage and precertification.
Conduct real‐time reviews of medical and surgical administrative denials and provide clinical recommendations to assist in resolution.
Work closely with concurrent case managers to understand payer‐specific contract requirements and develop preventative workflows for denials.
Support the pre‐certification and payer authorization process to ensure accurate and timely approvals that safeguard payment for services rendered.
Collaborate with third‐party payers to anticipate issues that could lead to denial of payment and act early to resolve those issues.
Serve as a resource and mentor for clinical and administrative staff across departments, answering questions and guiding staff through system‐wide denial management processes.
Attend monthly meetings with provider representatives from major insurance payers such as Aetna, Excellus, UHS, and WellCare to stay informed and advocate for resolution of systemic issues.
Work with physician offices, the Insurance Verification team, EHR analysts, and Care Managers to address administrative and medical necessity denials and keep teams updated on payer policies and process changes.
Position Qualifications:
Minimum Required: Associate in applied science in Nursing with a minimum of five (5) years of experience in acute/tertiary facility.
Minimum Required: NYS Licensed Registered Nurse
Preferred: Bachelor's of Science in Nursing with three (3) years of experience in acute / tertiary facility, denial management and/or revenue cycle experience.
Work Environment All work is performed in an office or on hospital units that requires working in close quarters with other employees. The areas are air conditioned as well as heated. Not exposed to environmental or toxic hazards. Age of Patients Served All Age Groups HIPAA Roles‐Based Access to Patient Information All ‐ Access to patient information, including restricted information ‐ Level 4. Required
Preferred
Job Industries
Other
Prepare and submit timely, well‐documented appeals for denied services to Medicare, Medicaid, and commercial payers, including Insurance Reviewers, Hearing Officers, and Administrative Law Judges.
Track and evaluate denial patterns to identify root causes and collaborate with internal teams to implement strategies that reduce future denials.
Work with providers and hospital departments to ensure services are billed under the correct admission status and that documentation supports billing requirements.
Partner with physician and hospital coders to ensure accurate CPT coding for emergency Medicare admissions and support correct hospitalization status determinations.
Collaborate with insurance verification staff to resolve authorization issues and address denials related to coverage and precertification.
Conduct real‐time reviews of medical and surgical administrative denials and provide clinical recommendations to assist in resolution.
Work closely with concurrent case managers to understand payer‐specific contract requirements and develop preventative workflows for denials.
Support the pre‐certification and payer authorization process to ensure accurate and timely approvals that safeguard payment for services rendered.
Collaborate with third‐party payers to anticipate issues that could lead to denial of payment and act early to resolve those issues.
Serve as a resource and mentor for clinical and administrative staff across departments, answering questions and guiding staff through system‐wide denial management processes.
Attend monthly meetings with provider representatives from major insurance payers such as Aetna, Excellus, UHS, and WellCare to stay informed and advocate for resolution of systemic issues.
Work with physician offices, the Insurance Verification team, EHR analysts, and Care Managers to address administrative and medical necessity denials and keep teams updated on payer policies and process changes.
Position Qualifications:
Minimum Required: Associate in applied science in Nursing with a minimum of five (5) years of experience in acute/tertiary facility.
Minimum Required: NYS Licensed Registered Nurse
Preferred: Bachelor's of Science in Nursing with three (3) years of experience in acute / tertiary facility, denial management and/or revenue cycle experience.
Work Environment All work is performed in an office or on hospital units that requires working in close quarters with other employees. The areas are air conditioned as well as heated. Not exposed to environmental or toxic hazards. Age of Patients Served All Age Groups HIPAA Roles‐Based Access to Patient Information All ‐ Access to patient information, including restricted information ‐ Level 4. Required
Preferred
Job Industries
Other