This is a hybrid position and must be located within 100 miles of any of the Mayo Clinic campuses for on-site expectations based on business needs.
Primary duties may include, but are not limited to, responsibility for reviewing assigned clinically related denials, payer audits, and payer correspondence as well as preparation of relevant appeal submission or audit responses. Utilizes clinical expertise and critical thinking in the evaluation of medical records against appropriate criteria and contract requirements and utilizes appropriate communication style to appeal or defend medically denied claims. Is a liaison and resource to revenue cycle, case management and practice stakeholders in defending clinically denied claims and providing relevant feedback to key stakeholders on denial prevention opportunities.
Minimum Education: Associates Degree
Minimum Experience: 3 years of relevant nursing experience
Current active unrestricted RN license.
The preferred applicant will have the following experience: Advanced knowledge of ICD-10-CM/PCS coding conventions, DRG reimbursement methodology, and clinical validation principles, with demonstrated ability to interpret Coding Clinic guidance and Medicare IPPS regulations to support accurate DRG assignment and defend coding-related denials.
Healthcare Financial Management Association (HFMA) Certification Preferred.
CCDS or CDIP Certification Preferred.
Experience in utilization review, case management, denials and appeals, revenue cycle, or prior authorization preferred. Knowledge and use of discharge planning, case management, utilization review, and levels of care criteria. Familiarity with Medicaid and Medicare claims denials and appeals processing and regulatory requirements. Knowledge and use of payer medical policy and Medicare LCD/NCD criteria. Knowledge of billing and coding requirements. Experience utilizing Milliman Care Guidelines and InterQual Criteria. Knowledge of current NCQA/URAC standards. Knowledge and experience applying 2-Midnight Rule Criteria. Knowledge and experience in Epic. Must have the ability to effectively utilize Microsoft Office Suite and possess basic data entry skills. Must possess excellent verbal, written and interpersonal communication skills, and able to balance multiple demands and respond to time constraints. Must have high-level skills in organization as well as problem solving and analytical skills.
**This vacancy is not eligible for sponsorship / we will not sponsor or transfer visas for this position.
Mayo Clinic has expanded and changed in many ways, but our values remain true to the vision of our founders. Our primary value – The needs of the patient come first – guides our plans and decisions as we create the future of health care. Join us and you'll find a culture of teamwork, professionalism and mutual respect, and most importantly, a life-changing career.
Mayo Clinic was founded in Rochester, Minnesota by brothers Dr. William James Mayo and Dr. Charles Horace Mayo. More than 100 years later, their vision continues to evolve around a single guiding value: "The needs of the patient come first." Today we are the largest integrated, not for-profit medical group practice in the world.
We are recognized for high-quality patient care more than any other academic medical center in the nation. These endorsements are very gratifying, but also humbling. They remind us of the tradition that has been entrusted to each one of us, and the legacy of excellence that we uphold every day.
