Clinical Appeals Spec.

About the Role

BJC Health Care is seeking a Clinical Appeals Specialist to assist with hospital billing for government and commercial plans. This individual will handle clinical denials, send them to a nurse to review and appeal, and 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.

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.

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 and write a compelling appeal.

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

• Responsible for all payers and have a clear understanding of payer contract language and BJC’s appeal rights. Uses 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 within BJC to explain trends identified that are causing payer denials; collaborates to develop best‑practice procedures to prevent denials.
• Effectively communicate with the Clinical Appeals team and work with contracted vendor partnerships.
• Lead various special projects as assigned by management.

• Education:
  
  High School Diploma or GED.
• Experience:
  
  2–5 years.

• Education:
  
  Bachelor's Degree.

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. Benefits available first day of the month after hire include comprehensive medical, dental, vision, life insurance and legal services; disability insurance paid for by BJC; annual 4 % BJC Automatic Retirement Contribution; 401(k) plan with BJC match;

tuition assistance; BJC Institute for Learning and Development;
Health Care and Dependent Care Flexible Spending Accounts; paid time off covering vacation, sick days, holidays and personal time; adoption assistance.

• Not all benefits apply to all jobs.

Equal Opportunity Employer.