Clinical Appeals Team Lead
Clinical Denial Nurse Team Lead | Responsibilities and Metrics
The Team Lead is a leadership position that brings business knowledge, innovation, and insight to create distinctive value for VBO and its clients while creating a culture of individual ownership and accountability for high performance. The Team Lead interfaces directly with: clients, Clinical Denial team members, and VBO Managers and Executive Leadership. All tasks related to this position are to be done in a manner consistent with VBO policies, procedures, quality standards, customer needs and applicable local, state and federal regulations. The purpose of this role is to support our VBO Clinical Denials team by providing client services related to clinical denials and appeals management. This position will be responsible for leading initiatives to work effectively with payers and providers, along with different members of the internal team of Clinicians, Nurses, Accounts Receivable Analysts, Coding team, and client leadership.
FLSA Status: Exempt
? Manages the internal clinical denial and appeals team members in a manner that diligently investigates Payer denied claims
? Assesses the need for formal appeals of clinical denials
? Ensures team members appeal the rejections appropriately as per the appeals process for the provider contract through quality control audits and initiatives.
? Reviews and audits clinical denial appeal letter documentation to ensure its sufficiency and high quality client deliverables
? Responsible for reporting and communicating trends related to denials and appeal turnover statuses to provide recommendations and updates for client engagement calls.
? Provides education including various resources to the clinical denial team in order to understand the appeals and denials clinical criteria; searches for supporting clinical evidence to support appeal arguments when existing resources are unavailable
? Identifies best practice workflows to ensure efficiency and alignment with client expectations
? Onboards, mentors and trains new hire clinical denial staff to policies and procedures as applicable.
? Adheres to appeal timelines as prescribed by payer agreements
?Employs the use of different technology systems and applications to evaluate clinical, coding and financial data
? Identifies coding and clinical documentation trends related to different cases and various insurance carriers; maintains related data and monitors payer response to appeal activity
? Provides information to leadership on patterns or trends associated with denials and appeals
? Evaluates and adheres to all clinical and billing policies, clinical guidelines, coding guidelines and regulations of both commercial and governmental payers
? Ensures clinical denial team is taking steps necessary to understand the quality assurance requirements to ensure procedural compliance and high quality client deliverables
? Oversees revenue cycle process improvement projects
Preferred Experience and Skills
? Minimum Degree: Associates degree or higher; current RN licensure
? Minimum Years of Experience: 3+ years of experience in a clinical denials, appeals, medical necessity setting. 1+ year of managerial experience.
? Software/Systems Experience: InterQual, Milliman Care Guidelines and EMR (e.g. Epic, Cerner, etc.) chart review experience.
? Excellent clinical denial writing skills with ability to mentor and train a team during the onboarding processes; Proficient in Microsoft Office (i.e., Word, Excel, PowerPoint, Visio, etc.)
Recruiting Solutions provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Recruiting Solutions complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities.
Recruiting Solutions expressly prohibits any form of workplace harassment based on race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, genetic information, disability, or veteran status.