Job Description

Clinical Appeals Specialist

Cancer care is all we do

Hope in healing

Cancer Treatment Centers of America® (CTCA®) takes a unique and integrative approach to cancer care. Our patient-centered care model is founded on a commitment to personalized medicine, tailoring a combination of treatments to the needs of each individual patient. At the same time, we support patients’ quality of life by offering therapies designed to help them manage the side effects of treatment, addressing their physical, spiritual and emotional needs, so they are better able to stay on their treatment regimens and get back to life. At the core of our whole-person approach is what we call the Mother Standard® of care, so named because it requires that we treat our patients, and one another, like we would want our loved ones to be treated. This innovative approach has earned our hospitals a Best Place to Work distinction and numerous accreditations. Each of us has a stake in the successful outcomes of every patient we treat.

Job Description:

The Specialist, Clinical Appeals RN role is responsible for the coordination and completion of clinical appeals for denied claims. This includes investigating the reason of the denial, review of the guidelines and documentation on the medical record related to the denied services, maintaining a record of the action taken and meeting time frame requirements of various insurance plans. The Specialist has a direct impact on financial and operational goals through timely review and submission of appeal. The role is responsible for reducing impact to accounts receivables by discovering ongoing denials and notifying appropriate front end teams and implementing improvements which will result in reducing turnaround time for appeal submission. The role also includes responsibility for performing Pre-Service Medical Necessity reviews and completing expedited pre-service appeals. This requires daily prioritization of workflow and communication with providers and clinical teams. The Specialist has a direct impact on Denials Mitigation efforts across the enterprise to reduce clinical denials volume and positively impact reimbursement of services.

The Specialist will assist the Manager, Clinical Appeals in discovering denial issues and trends impacting revenue through by analyzing and documenting trended information. The Specialist will create and implement best practice techniques and processes to drive departmental innovation and continuous improvement initiatives.

This role will report directly to Manager, Clinical Appeals and assists Manager with findings and opportunities for improvement.  This role will serve as a resource for Patient Accounts, Medical Records, Finance, Compliance and Revenue Producing Departments related to any issues or clinical denial questions.

Education/Experience Level

  • Must be an RN, BSN Preferred.
  • Minimum of 3-5 years clinical experience, clinical oncology preferred
  • Basic understanding of insurance claims processing, CPT/ICD-10 codes
  • Proficiency with Microsoft Office, especially Excel
  • Strong organizational and communication skills
  • Organized and efficient in prioritizing and managing workload with minimal oversight   

Knowledge and Skills

  • Must have good written and verbal communication skills
  • Basic understanding of financial reimbursement and revenue cycle operations in a provider organization
  • Must have basic knowledge of medical terminology
  • Must have experience with ICD-10 coding, insurance terminology and ability to read an Explanation of Benefits
  • Must have ability to look up CPT codes
  • Ability to bridge communication among financial and non-financial project staff
  • Must be able to perform routine mathematical, color coding and alphabetizing functions
  • Preferred to be familiar with Lean Six Sigma, SMART goal techniques

We win together

Each CTCA employee is a Stakeholder, driven to make a true difference and help win the fight against cancer. Each day is a challenge, but this unique experience comes with rewards that you may never have thought possible. To ensure each team member brings his or her best self, we offer exceptional support and immersive training to encourage your personal and professional growth. If you’re ready to be part of something bigger and work with a passionate, dynamic group of care professionals, we invite you to join us. 

Visit:  Jobs.cancercenter.com to begin your journey.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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