The Role
Handles denied medical claims requiring clinical review, coordinates administrative and medical appeals, and submits documentation to payers and state agencies. Analyzes denial trends, researches payer issues, resolves claim problems affecting revenue, facilitates internal appeals, and identifies coding or clinical documentation deficiencies. The role also supports quality improvement through education and continuing training while maintaining efficient departmental operations.
Summary Generated by Built In
"Responsible for handling administrative and medical appeals that require clinical input or interpretation, directing and coordinating all aspects of denied claims, provide coordination of comprehensive clinical documentation to third-party payers and state agencies to secure accurate payment, and the ability to identify coding or clinical documentation issues. "
Responsibilities- Analysis and Recommendations
- Provides on-going trend analysis to identify reasons for denials and apply corrective actions steps to prevent cash flow retardation.
- Proactively researches and understands payer issues. Troubleshoots and resolves issues that impact revenue. Responsible for facilitating the internal appeal process.
- Actively works through denied claims and attempts to gather information and take appropriate action to ensure claim is adjudicated properly.
- Quality
- Promotes the quality and efficiency of his/her own performance through participation in staff educational programs, approved continuing education courses, and specialized skill training programs.
- Utilizes all equipment, supplies, facilities, and resources in a prudent and efficient manner in order to ensure efficient departmental operations and the provision of high-quality health care services.
- Other Duties as Assigned
- Performs other duties as assigned or requested.
Education - Graduate of accredited school of nursing
Licensure - Current Louisiana State license as RN
Skills Required
- Graduate of an accredited school of nursing
- Current Louisiana State license as a Registered Nurse
Am I A Good Fit?
Get Personalized Job Insights.
Our AI-powered fit analysis compares your resume with a job listing so you know if your skills & experience align.
Success! Refresh the page to see how your skills align with this role.
The Company
What We Do
FMOL Health is a large, non-profit, Catholic healthcare system sponsored by the Franciscan Missionaries of Our Lady, providing faith-based, quality, and compassionate care in Louisiana and Mississippi.
