Clinical Appeals Specialist - Registered Nurse

Clinical Appeals Specialist - Registered Nurse

Join the transformative team at City of Hope , where we're changing lives and making a real difference in the fight against cancer, diabetes, and other life-threatening illnesses. City of Hope’s growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and treatment facilities in Atlanta, Chicago and Phoenix. our dedicated and compassionate employees are driven by a common mission: To deliver the cures of tomorrow to the people who need them today.

The successful candidate:

The Specialist, Clinical Appeals is responsible for the coordination and completion of clinical appeals for denied claims. This includes investigating denial reasons, reviewing guidelines and documentation on the medical record related to the denied services, maintaining records of the actions taken and meeting time frame requirements of various insurance plans. The Specialist has a direct impact on financial and operational goals through timely review and submission of appeal. The role is responsible for reducing impact to accounts receivables by discovering ongoing denials and notifying appropriate front end teams and implementing improvements which will result in reducing turnaround time for appeal submission.

The Specialist will assist department leadership in discovering and documenting denial issues and trends impacting revenue and will create and implement best practice techniques and processes to drive departmental innovation and continuous improvement initiatives. This role will serve as a resource for Patient Accounts, Medical Records, Finance, Compliance and Revenue Producing Departments.

Minimum Job Qualifications

Education: Graduate of an accredited Nursing Program

Licensure/ Certification: Active Registered Nurse License

Experience: 3-5 years clinical experience

Knowledge, Skills, Abilities:

• Basic understanding of insurance claims processing, CPT, ICD codes, Insurance and Medical Terminology, HIPAA

• Basic understanding of financial reimbursement and revenue cycle operations in a provider organization

• Ability to bridge communication among financial and non-financial project staff

• Must be efficient, reliable, goal orientated and adaptable to change while maintaining productivity levels

• Team oriented, courteous and professional

• Strong organizational and communication skills, able to prioritize and manage workload with minimal oversight

• Efficient in prioritizing and managing workload with minimal oversight

• Capable of operating all required computer applications and new applications as they are implemented

• Proficient with Microsoft Office Suite, Excel

Preferred Attributes

• BSN

• Clinical Oncology experience - 5 years preferred

City of Hope is an equal opportunity employer. To learn more about our commitment to diversity, equity, and inclusion, please click here .

To learn more about our comprehensive benefits, click here: Benefits Information