Senior Denials RN Specialist, Anywhere OH

R037607 Thank you for considering a career at Ensemble Health Partners! Ensemble Health Partners is a leading provider of technology-enabled revenue cycle management solutions for health systems, including hospitals and affiliated physician groups. They offer end-to-end revenue cycle solutions as well as a comprehensive suite of point solutions to clients across the country. Ensemble keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we believe that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status quo, we know they will be the difference! 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: CAREER OPPORTUNITY OFFERING: • Bonus Incentives • Paid Certifications • Tuition Reimbursement • Comprehensive Benefits • Career Advancement • This position pays between $62,500.00 - $79,800.00/ based on experience The Sr Specialist Denial RN prepares appeals for clinical and technical claim denials across all client hospital facilities. Job duties include but are not limited to: understanding insurance contract terms, reviewing claim denials and underpayments to determine if additional payment amounts can be expected, analyzing medical records and determining if a member or an Independent Review organization (IRO) appeal is necessary, understanding payer medical policy guidelines, preparing IRO appeal documentation which may include correcting and resubmitting claims, gathering additional information, reviewing medical records, acting as a liaison between healthcare providers for any additional medical documentation or clarification, and submitting provider, member and IRO/ALJ appeals in a timely manner. Knowledge and understanding of ERISA compliance laws, healthcare provider and member's legal rights regarding member appeal and grievance processes. Ensures compliance with HIPAA regulations. In addition, the Sr Specialist Denial RN will work closely with the Clinical Appeal team and Case Management Department to ensure denial trends and outcomes are communicated in a timely manner. Serves as a mentor and provides necessary training and education to Clinical Denial and Underpayment team members. The Sr Specialist Denial RN will perform these duties while meeting Ensemble principles, as well as meeting the regulatory compliance requirements. Essential Job Functions: • Sr Specialist Denial RN 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: 5 to 7 years Preferred Knowledge, Skills and Abilities: • 4 year/ Bachelors Degree • 2 years of denials, utilization review, or case management experience strongly preferred • 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 Join an award-winning company Five-time winner of “Best in KLAS” 2020-2022, 2024-2025 Black Book Research's Top Revenue Cycle Management Outsourcing Solution 2021-2024 22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in Revenue Cycle 2019-2024 Leader in Everest Group's RCM Operations PEAK Matrix Assessment 2024 Clarivate Healthcare Business Insights (HBI) Revenue Cycle Awards for strong performance 2020, 2022-2023 Energage Top Workplaces USA 2022-2024 Fortune Media Best Workplaces in Healthcare 2024 Monster Top Workplace for Remote Work 2024 Great Place to Work certified 2023-2024 • Innovation • Work-Life Flexibility • Leadership • Purpose + Values Bottom line, we believe in empowering people and giving them the tools and resources needed to thrive. A few of those include: • Associate Benefits – We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs. • Our Culture – Ensemble is a place where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation. • Growth – We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement. • Recognition – We offer quarterly and annual incentive programs for all employees who go beyond and keep raising the bar for themselves and the company. Ensemble Health Partners 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 Health Partners also prohibits harassment of applicants or employees based on any of these protected categories. Ensemble Health Partners 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 [email protected]. 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.