Clinical Coordinator - Denials - ECU Health

ECU Health

About ECU Health

ECU Health is a mission-driven, 1,708-bed academic health care system serving more than 1.4 million people in 29 eastern North Carolina counties. The not-for-profit system is comprised of 13,000 team members, nine hospitals and a physician group that encompasses over 1,100 academic and community providers practicing in over 180 primary and specialty clinics located in more than 130 locations.

The flagship ECU Health Medical Center, a Level I Trauma Center, and ECU Health Maynard Children’s Hospital serve as the primary teaching hospitals for the Brody School of Medicine at East Carolina University. ECU Health and the Brody School of Medicine share a combined academic mission to improve the health and well-being of eastern North Carolina through patient care, education and research.

Position Summary

Coordinates the appeals process, data entry, and analysis for governmental and commercial denials across ECU Health. Liaison between internal and external parties to ensure timelines are met with regard to appeal preparation and submission. Monitors progression of appealed cases through final appeal process. Acts as software expert to ensure automation enhances the efficiency of the appeals process.

Responsibilities

• Coordinates collection of payer medical policies and regulatory guidelines for review by Director of Clinical Denials Management or other key stakeholders as appropriate.
• Coordinates and maintains an electronic medical policy library by payer which may easily be resourced and referenced for conducting peer-to-peer reviews and consults, case management, discharge planning, and managing and challenging denials.
• Coordinates collection of medical policy updates from commercial payers and ensures widest dissemination to key stakeholders to ensure awareness and compliance with medical policy updates in an effort to prevent avoidable denials
• Performs primary data entry for all denials related to medical necessity into appropriate database to ensure day-to­day tracking and reporting of appeal deadlines and at risk revenues.
• Updates databases in order to reflect current status of denied cases throughout appeals process. Advises Director of Clinical Denials Management of areas of concern 

Minimum Requirements

• Business or Computer Sciences major.
• Progressive experience in utilization management and appeal/denial management.
• Database management, data entry, process management, familiarity with appeals management principles; clinical setting preferred.
• Associate Degree or higher
• Five to seven years related experience

Other Information

• This position is On-site

General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.

General Statement

It is the goal of ECU Health and its entities to employ the most qualified individual who best matches the requirements for the vacant position.

Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

We value diversity and are proud to be an equal opportunity employer. Decisions of employment are made based on business needs, job requirements and applicant’s qualifications without regard to race, color, religion, gender, national origin, disability status, protected veteran status, genetic information and testing, family and medical leave, sexual orientation, gender identity or expression or any other status protected by law. We prohibit retaliation against individuals who bring forth any complaint, orally or in writing, to the employer, or against any individuals who assist or participate in the investigation of any complaint.