Denials Prevention Specialist, Clinician PRN

Datavant is a data platform company and the world's leader in health data exchange. Our vision is that every healthcare decision is powered by the right data, at the right time, in the right format.

Our platform is powered by the largest, most diverse health data network in the U.S., enabling data to be secure, accessible and usable to inform better health decisions. Datavant is trusted by the world's leading life sciences companies, government agencies, and those who deliver and pay for care.

By joining Datavant today, you're stepping onto a high-performing, values-driven team. Together, we're rising to the challenge of tackling some of healthcare's most complex problems with technology-forward solutions. Datavanters bring a diversity of professional, educational and life experiences to realize our bold vision for healthcare.

The purpose of the Denial Prevention Specialist is to effectively defend utilization of available health services, review of admissions for medical necessity and necessity of continued stay in the inpatient patient care setting and/or discharge to an alternative level of care. Using nationally recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise successfully.

Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in DRG downgrade denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payor guidelines.**

You will:

• Provide timely referral/appeal determination by accurate

• Work under the usage of the Milliman Care Guidelines and or Interqual

• Select appropriate letter language to author appeal letter Identification of referrals to the medical director for review

• Select appropriate preferred and contracted providers

• Provide proper identification of eligibility and healthcare plans

• Maintain compliance in turnaround time requirements as mandated by the TAT Standards of the facility and/or CIOX Health Standards

• Work directly with the provider(s) and health plan Medical Director as needed to facilitate timely authorizations and/or denial reversals

• Maintain and keeps in total confidence, all files, documents and records

• Meets or exceeds production and quality metrics

• Attend all mandatory meetings and trainings All other job-related duties as it relates to job function as delegated by management

Ideal candidate should be a Licensed Practical Nurse or Registered Nurse well versed in DRG downgrade denials and appeal writing for inpatient admission. Experience with clinical criteria resources and payor guidelines. *

What you will bring to the table:

• Two (2) years managed care experience in UM/CM/CDI Department preferred

• Knowledge of CMS, State Regulations, URAC and NCQA preferred

• ICD10 and CPT coding a plus

• Experienced computer skills, Word, Excel, Outlook, experience working in a health plan medical management documentation system a plus.

Minimum Education: LVN/LPN

• Preferred Education: BA or BS in Nursing, experience preferred to perform

• Minimum Experience: 3 to 5 years acute care experience

• 2 years Health Plan or Acute Care UR/CM

• Preferred Experience: 5 years acute care or health plan UR/CM with 1 year ICU/ER

We are committed to building a diverse team of Datavanters who are all responsible for stewarding a high-performance culture in which all Datavanters belong and thrive. We are proud to be an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, or other legally protected status.

Our compensation philosophy is to be externally competitive, internally fair, and not win or lose on compensation. Salary ranges for this position are developed with the support of benchmarks and industry best practices.

We're building a high-growth, high-autonomy culture. We rely less on job titles and more on cultivating an environment where anyone can contribute, the best ideas win, and personal growth is driven by expanding impact. The range posted is for a given job title, which can include multiple levels. Individual rates for the same job title may differ based on their level, responsibilities, skills, and experience for a specific job. The estimated salary range for this role is $22 - $45

Pay ranges for this job title may differ based on location, responsibilities, skills, experience, and other requirements of the role.

The estimated base pay range per hour for this role is:

$22-$45 USD

To ensure the safety of patients and staff, many of our clients require post-offer health screenings and proof and/or completion of various vaccinations such as the flu shot, Tdap, COVID-19, etc. Any requests to be exempted from these requirements will be reviewed by Datavant Human Resources and determined on a case-by-case basis. Depending on the state in which you will be working, exemptions may be available on the basis of disability, medical contraindications to the vaccine or any of its components, pregnancy or pregnancy-related medical conditions, and/or religion.

This job is not eligible for employment sponsorship.

Datavant is committed to a work environment free from job discrimination. We are proud to be an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, or other legally protected status. To learn more about our commitment, please review our EEO Commitment Statement here () . Know Your Rights () , explore the resources available through the EEOC for more information regarding your legal rights and protections. In addition, Datavant does not and will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay.

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