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 Education: Associates Degree
Minimum Experience: 3 years of relevant nursing experience
Current active unrestricted RN license.
The preferred applicant will have the following experience: Prior Authorization 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 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.During the selection process, you may participate in an OnDemand (pre-recorded) interview that you can complete at your convenience. During the OnDemand interview, a question will appear on your screen, and you will have time to consider each question before responding. You will have the opportunity to re-record your answer to each question - Mayo Clinic will only see the final recording. The complete interview will be reviewed by a Mayo Clinic staff member and you will be notified of next steps.
Job details are sourced from the employer's original posting.
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Mayo Clinic is a nonprofit academic medical center focused on integrated health care, education, and research.