Clinical Appeals Specialist II-Hybrid

About the role

Why Mayo Clinic Mayo Clinic is top-ranked in more specialties than any other care provider according to U.S. News & World Report. As we work together to put the needs of the patient first, we are also dedicated to our employees, investing in competitive compensation and comprehensive benefit plans – to take care of you and your family, now and in the future. And with continuing education and advancement opportunities at every turn, you can build a long, successful career with Mayo Clinic. Just as our reputation has spread beyond our Minnesota roots, so have our locations. Today, our employees are located at our three major campuses in Phoenix/Scottsdale, Arizona, Jacksonville, Florida, Rochester, Minnesota, and at Mayo Clinic Health System campuses throughout Midwestern communities, and at our international locations. Each Mayo Clinic location is a special place where our employees thrive in both their work and personal lives.

Responsibilities

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.

Qualifications

• Minimum Education: Associates Degree
• Minimum Experience: 3 years of relevant nursing experience
• Current active unrestricted RN license
• Preferred: Prior Authorization Experience
• Preferred: 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
• Preferred: 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
• Preferred: Familiarity with Medicaid and Medicare claims