Clinical Appeals Specialist

Additional Information About the Role

BJC Health Care is seeking a Clinical Appeals Specialist to assist with infusion appeals for both government and commercial plans.

This individual will be handling clinical denials and sending them to a nurse to review and appeal and then they will follow up on the appeal. Ideal candidates will have a background in denial follow up and/or prior authorization.

BJC Health Care is one of the largest nonprofit health care organizations in the United States, delivering services to residents primarily in the greater St. Louis, southern Illinois and southeast Missouri regions. With net revenues of $6.3 billion and more than 30,000 employees, BJC serves patients and their families in urban, suburban and rural communities through its 14 hospitals and multiple community health locations.

Services include inpatient and outpatient care, primary care, community health and wellness, workplace health, home health, community mental health, rehabilitation, long‑term care and hospice.

BJC is the largest provider of charity care, unreimbursed care and community benefits in the state of Missouri. BJC and its hospitals and health service organizations provide $785.9 million annually in community benefit, including $410.6 million in charity care and other financial assistance to patients to ensure medical care regardless of their ability to pay. In addition, BJC provides additional community benefits through commitments to research, emergency preparedness, regional health care safety net services, health literacy, community outreach and community health programs and regional economic development.

BJC’s patients have access to the latest advances in medical science and technology through a formal affiliation between Barnes‑Jewish Hospital and St. Louis Children’s Hospital with the renowned Washington University School of Medicine, which consistently ranks among the top medical schools in the country.

Role Purpose

Responsible for resolving clinical denials for BJC hospitals and payors. The Clinical Appeals Specialist must be able to multi‑task and maintain a high level of professionalism when communicating with payors, and hospitals. In addition to writing appeals, the Clinical Appeals Specialist must be proficient in using web‑based payor portals such as Allscripts and Vital Ware to review documentation to write a compelling appeal.

The Clinical Appeals Specialist must be able to identify trends and escalate them to the appropriate department. Acts as a resource for other team members and provides education to hospital partners as needed.

Responsibilities

• Responsible for all payers and having a clear understanding of payer contract language and BJC’s appeal rights. Works in EPIC to identify correct patient status order.
• Understands Revenue Cycle Management and hospital partner’s processes. Provides education for opportunities to prevent denials and avoidable adjustments.
• Prepare and present to a variety of partners among BJC to aid in explaining trends identified that are causing payer denials. Collaborates to develop best practices procedures to prevent denials.
• Effectively communicates with the Clinical Appeals team and works with contracted vendor partnerships.
• Lead various special projects as assigned by management.

Minimum Requirements

Education

• High School Diploma or GED

Experience

• 2‑5 years

Preferred Requirements

Education

• Bachelor’s Degree

BJC Total Rewards

At BJC we’re committed to providing you and your family with benefits and resources to help you manage your physical, emotional, social and financial well‑being.

• Comprehensive medical, dental, vision, life insurance, and legal services available first day of the month after hire date
• Disability insurance
  * paid for by BJC
• Annual 4% BJC Automatic Retirement Contribution
• 401(k) plan with BJC match
• Tuition Assistance available on first day
• BJC Institute for Learning and Development
• Health Care and Dependent Care Flexible Spending Accounts
• Paid Time Off benefit combines vacation, sick days, holidays and personal time
• Adoption assistance

To learn more, go to our Benefits Summary

* Not all benefits apply to all jobs

The above information on this description has been designed to indicate the general nature and level of work performed by employees in this position. It is not designed to contain or be interpreted as an exhaustive list of all responsibilities, duties and qualifications required of employees assigned to this job. Equal Opportunity Employer