Majestic Care Staffing is looking for
Corporate Denials and Appeals Specialist to join our teams’ mission and believe in our core values!
Our mission:
Through the hearts of our Care Team Members, we provide excellent healthcare to those we serve.
Our Core Values...
L - Listening
E - Empathy
A - Accountability
D - Decisiveness
This is how we create a culture to LEAD with Love.
Through the hearts and minds of our care team members, we provide excellent healthcare to those we serve. With a vision of innovating healthcare by keeping those we serve at the heart of our mission, we provide tools, processes, support resources, data analytics, and insource strategies that drive results.
Position Overview:
The Corporate Compliance Clinical Audit Specialist is a key member of the Corporate Compliance & Ethics team. The primary responsibility of this position is to audit our post-acute care facilities for compliance with the Office of Inspector General’s (OIG) compliance program specific to skilled nursing facilities, home health and Hospice, as well as general best practices in the post-acute care industry and organizational policies.
Key Responsibilities:
- Responsible for the development and implement new care team member orientation training programs related to PCC
- Creates and delivers intermittent re-training plans for clinical care team members as needed
- Facilitates on-site support programs and troubleshoot internal user questions/problems as they arise.
- Responsible for keeping abreast of all releases of PCC system and manages all communication to any impact to users.
- Maintains oversight by monitoring the PCC environments to ensure integrity of data.
- Extract data/reports for Senior Leadership and Leadership within our communities upon request.
- Serves as a liaison for all PCC integrations for new acquisitions.
Essential Job Functions:
Compliance Auditing and Oversight
- Conduct retrospective, concurrent, and prospective audits of medical records across skilled nursing, home health, and hospice settings to assess compliance with billing, coding, documentation, and quality standards.
- Identify discrepancies, errors, or potential non-compliance with federal/state regulations, payer requirements, and internal policies.
- Lead and manage internal compliance audits, ensuring timely completion, accurate documentation, and development of corrective action plans.
- Track audit outcomes and collaborate with stakeholders to implement monitoring strategies that support sustained compliance.
Denials Management and Audit Response
- Triage pre- and post-payment audit findings and denials submitted by facilities, payers, or payer portals, and route them to the appropriate teams for resolution.
- Initiate tracking processes and ensure awareness of timelines and timely filing requirements.
- Conduct detailed reviews of denied claims to identify specific reasons for denial.
- Perform root cause analysis to determine underlying issues such as coding errors, lack of authorization, or billing discrepancies.
- Prepare and submit appeals with supporting documentation, ensuring compliance with payer-specific appeal levels, timelines, and expectations.
- Develop and implement denial prevention strategies, including process improvements, staff training, and enhanced communication.
- Collaborate with internal departments to address denial trends and improve audit outcomes.
- Analyze denial data to identify patterns, track resolution progress, and evaluate the effectiveness of denial management efforts.
- Ensure all activities comply with HIPAA regulations and payer guidelines.
- Communicate effectively with payers, providers, and internal teams to resolve denials and enhance processes.
- Maintain accurate and up-to-date records of all denial management activities.
- Support the evaluation and improvement of organizational policies and procedures to strengthen compliance and operational efficiency.
- Develop and deliver training programs on denial management, compliance requirements, and best practices.
- Stay current with regulatory changes and payer policy updates. Provide support for compliance-related initiatives and special projects as needed.
Education
- Bachelor’s degree required; equivalent work experience may be considered.
Licenses and Certifications
- Certified in Healthcare Compliance (must be obtained within one year of hire).
- Coding credentials (must be obtained within one year of hire).
Experience
- Strong operations background
- Compliance or healthcare/post-acute care experience, including billing, coding, or documentation (HIM)
- Experience conducting compliance audits in clinical or administrative settings
- Proficiency with electronic health records (EHRs) and healthcare documentation systems
Knowledge, Skills, And Abilities
- Expert knowledge of medical billing, coding, and insurance claims processing (preferably in post-acute)
- Familiarity with payer portals, appeals, workflows, and EMR systems
- Excellent analytical and problem-solving skills
- Proficiency in using healthcare information systems and payer portals
- Effective communication and interpersonal skills
- Ability to work independently or as part of a team
- Familiarity with denial management best practices.
- Ability to work independent of supervision.
- Ability to establish and manage relationships.
- Ability to manage time and set priorities amidst multiple tasks and deadlines with little supervision.
- Strong creativity and problem-solving skills
- Ability to maintain confidentiality when working with sensitive information is essential.
- Expert-level O365 Suite experience required (Teams, Lists, etc.)
- Proactive, critical thinker, diplomatic, customer focus, action/results oriented, and strong collaborator across organizational lines
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