Clinical Denial/Utilization Management Assistant

Overview

The Clinical Denial/Utilization Management Assistant provides support to the Clinical Denial Management and Utilization Review teams. The assistants are responsible for the maintenance and utilization of EPIC work queues that drive payer notification and authorization for patient stays. The associate communicates with payers via telephone, fax, or email, and is responsible for ensuring clinical requests are sent in a timely manner and in a thorough fashion. This role is pivotal in the clinical denial appeal process. Provides support before the creation of the appeal and after the appeal is sent to the payer. The Assistant helps with tracking of key information related to the life span of the clinical appeal.

Responsibilities

Communicates effectively with Clinical Denial Management and Utilization Review teams to ensure denial letters are addressed in a timely manner. Reviews denials sent by payers and documents them into the Dragonfly software, EMR and/or tracking tool as appropriate to ensure appropriate tracking is maintained. Communicates with Clinical Denial Management and Utilization Review teams to help create strong processes and efficiencies. Submits all appeal documents to the payer accurately and timely. Organizes and maintains all clinical appeal documents, databases, and records in a systematic way. Reviews appealed cases in a systematic and timely fashion to ensure payment is received and notifies Clinical Denials Management team of new findings of review. Contacts insurance provider as directed when more information is needed. Gathers data for reporting purposes. Screens incoming calls, faxes or other digital communications related to clinical denials and directs it to the appropriate area. Perform projects, reviews and handles reports as assigned. Interacts with hospital, provider, and financial staff regarding determinations, appeals, and denials and gives direction as necessary.

Qualifications

Certifications: , Education: , Work Experience:

Carle Health Company Overview

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Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.

 

Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois.  We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.

 

 

 

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information: human.resources@carle.com.

Salary Range

The compensation range for this position is $17.12per hour - $27.73per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.