Denials RN Coordinator

O.N.E Purpose

Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.
Embracing New Ideas: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.
Striving for Excellence: Execute at a high level by demonstrating our “Best in KLAS” Ensemble Difference Principles and consistently delivering outstanding results.

The Opportunity

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement

This position pays between $62,500.00 - $79,800.00/ based on experience

Essential Job Functions

• Denials RN Coordinator primary responsibility is the review of complex claims and escalating clinical or technical claim denials for potential provider, member level or IRO/ALJ appeal.
• Extensive review of medical records for medical necessity criteria, filing written letters of appeal on denied claims, filing complaints with state Department of Insurance, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting appeals in a timely manner.
• Reviewing claim denials and underpayments to determine if additional payment amounts are expected and identifying trends in payment discrepancies amongst payors.
• Work closely with the Clinical Denial team and Case Management Department to ensure denial trends and outcomes are communicated in a timely manner.
• Acts as a mentor and provides necessary training and education to Clinical Denial and Underpayment team members.
• Performs other duties as assigned.

Legally Required License

Registered Nurse RN

Job Experience

• 4 year/ Bachelors Degree
• 2 years of denials, utilization review, or case management experience strongly preferred

Preferred Knowledge, Skills and Abilities

• Must pass typing test of 45 words per minute (error adjusted)
• 5+ Years of experience in: Revenue Cycle, Legal nurse consulting, Chart audit/review, Provider relations, Internal Candidate must have met 100% productivity and 100% Quality Assurance, in the previous 3 months
• Demonstrated advanced usage of AI and the management of teams using AI to lean in to process and technological improvements, to include the exploration, experimentation, and application of AI

Employment Disclaimers

Employment decisions are based on the individual's qualifications, experience, and abilities. Ensemble is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national origin, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws. Ensemble also prohibits harassment of applicants or employees based on any of these protected categories. Ensemble provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act and applicable state and local law. If you require accommodation in the application process, please contact TA@ensemblehp.com. This posting addresses state specific requirements to provide pay transparency. Compensation decisions consider many job-related factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position. A candidate entry rate of pay does not typically fall at the minimum or maximum of the role’s range. Employment Disclaimers – Ensemble