The Insurance Communication Analyst in the Managed Care Department under the direction of the Manager, Insurance Communications provides clinical and administrative expertise to the appeal function. Creates strategy for addressing specific claim denials. Works cooperatively with patient's families, departments throughout the hospital and with physicians and their office staff to assure the creation and timely submission of a persuasive, technical, and accurate appeal document. Works effectively with all payor representatives. Demonstrates flexibility and creativity in the function. Represents the department in all appeal activities. Maintains data on all appeals and their outcomes. Creates, augments and maintains files of resources on legislation, state or payor initiatives and supportive arguments to be utilized in refuting denials. Demonstrates significant success in reversing third party payor denials as measured by pre-determined performance requirements. Creates, on a routine basis, all Managed Care downloads and appeal reports. Drafts policies and procedures on this subject. Works with any consulting firms and other departments to maximize recovery of denials. Completes national centers of excellence surveys for transplant and oncology. (CB)
Bachelor's degree in a health-related field, RHIA or RN preferred.
Master's degree preferably in a clinical or research field strongly preferred.
Two (2) additional years of related work experience may be substituted by the Master's degree.
A minimum of three (3) years’ experience working in a medical or health insurance plan setting is required.
RN, RHIA or similar licensure preferred.
St. Jude Children's Research Hospital - 17 months ago
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St. Jude Children's Research Hospital studies and treats catastrophic diseases in children, especially pediatric cancers. The hospital,...