Senior Claim Denial Prevention & Appeals Specialist

Job Description

Oracle Clinical AI Assistant (CAA) allows providers and their support staff to focus more on patient care by reducing administrative burden of clinical and reimbursement tasks such as charting, documentation, and coding by applying power of generative AI. Our diverse team of creators and inventors are building the future of conversational clinical interfaces, making real improvements in the lives of people across the world. We act with the speed and attitude of a start-up, but with the scale and customer focus of the world's leading enterprise software company. We have a big charter and a lot of creative freedom to get it done. Come join us and grow your career in this exciting arena.

We are looking for a Senior Claims Denial Prevention and Appeals Specialist for providing clinical inputs to engineering for developing the Claim Denial Prevention and Appeals features of Oracle Health Clinical AI Agent (CAA). This role leverages expert clinical judgment and regulatory knowledge (e.g., medical necessity, level of care, clinical validation) to lead the appeals initiative to review denied claims, create write-ups for appeals packets, identify trends/improvement opportunities to prevent future denials, and ensure maximum appropriate reimbursement. This role is critical for financial recovery and ultimate prevention of complex, high-dollar claim denials.

Qualifications

• 3+ years hands on experience preparing appeals for claim denials in the hospital and ambulatory setting

• 3+ years hands on experience in analyzing claim denials and formulating strategies for preventing future denials

• Background knowledge of HIM field helpful, with focus on different reimbursement methodologies, AHA coding guidelines, and Clinical Documentation Improvement experience.

• Knowledge of medical and insurance terminology, MS-DRG, APR-DRG, CPT, ICD coding structures, and billing forms (UB, 1500).

• Experience with coding, clinical validation, and medical necessity for outpatient and inpatient stays.

• Knowledge of third-party payor rules and regulations.

• 2-3 years of Utilization Review experience in a healthcare setting preferred; 1-2 years of experience in hospital audits preferred

• Associate or bachelor's degree in nursing from an accredited college and AHIMA Certified RHIT credentials preferred

• Certification in Utilization Review, case management, and healthcare quality preferred

Responsibilities

• Act as subject matter expert (SME): Provide expertise for Claim denial prevention and appeals submission workflows, different payer requirements, and clinical/administrative use cases to identify inefficiencies and opportunities for automation. Work closely with technical teams as the knowledge lead for denial prevention and appeals creation processes.

• Denied Claims Review and Appeal Drafting: Conduct in-depth clinical reviews of denied claims, utilize medical records, medical necessity criteria, payer reimbursement guidelines/payment policies to determine appeal viability, prepare evidence-based appeal correspondence across all levels of appeals process.

• Denial Prevention: Analyze denial data to accurately identify trends, patterns, and root causes of recurrence, identify documentation gaps and systemic process failures related to denials, identify concrete recommendations and articulate the necessary steps required to be implemented in the pre-claim submission workflows to prevent future denials

• Cross-functional Collaboration : Work with product, engineering, and applied science teams to ensure alignment with medical necessity guidelines, payer policies, and clinical protocols. Provide input and expertise into the automation strategy across reimbursement (revenue cycle) workflows, ensuring alignment with organizational goals and industry standards and guidelines.

• Regulatory Compliance : Stay current with regulatory requirements related to claims processing across payers and government entities such as CMS/state Medicaid, maintain current knowledge of payer policies and medical necessity criteria, CMS national and local coverage determinations affecting billing and ensuring that workflows meet all necessary compliance.

Leading contributor individually and as a team member. Work is very complex, involving the application of advanced technical/business skills in area of specialization. Ability to collect, organize, and display data in spreadsheet format. Follow-through skills necessary to get information implemented into incremental model development improvements. For this, relationship management skills strongly desired. Strong written and verbal communication skills.

Disclaimer:

Certain US customer or client-facing roles may be required to comply with applicable requirements, such as immunization and occupational health mandates.

Range and benefit information provided in this posting are specific to the stated locations only

US: Hiring Range in USD from: $75,000 to $178,100 per annum. May be eligible for bonus and equity.

Oracle maintains broad salary ranges for its roles in order to account for variations in knowledge, skills, experience, market conditions and locations, as well as reflect Oracle's differing products, industries and lines of business.

Candidates are typically placed into the range based on the preceding factors as well as internal peer equity.

Oracle US offers a comprehensive benefits package which includes the following:

Medical, dental, and vision insurance, including expert medical opinion

Short term disability and long term disability

Life insurance and AD&D

Supplemental life insurance (Employee/Spouse/Child)

Health care and dependent care Flexible Spending Accounts

Pre-tax commuter and parking benefits

401(k) Savings and Investment Plan with company match

Paid time off: Flexible Vacation is provided to all eligible employees assigned to a salaried (non-overtime eligible) position. Accrued Vacation is provided to all other employees eligible for vacation benefits. For employees working at least 35 hours per week, the vacation accrual rate is 13 days annually for the first three years of employment and 18 days annually for subsequent years of employment. Vacation accrual is prorated for employees working between 20 and 34 hours per week. Employees working fewer than 20 hours per week are not eligible for vacation.

11 paid holidays

Paid sick leave: 72 hours of paid sick leave upon date of hire. Refreshes each calendar year. Unused balance will carry over each year up to a maximum cap of 112 hours.

Paid parental leave

Adoption assistance

Employee Stock Purchase Plan

Financial planning and group legal

Voluntary benefits including auto, homeowner and pet insurance

The role will generally accept applications for at least three calendar days from the posting date or as long as the job remains posted.

Career Level - IC4

About Us

As a world leader in cloud solutions, Oracle uses tomorrow's technology to tackle today's challenges. We've partnered with industry-leaders in almost every sector-and continue to thrive after 40+ years of change by operating with integrity.

We know that true innovation starts when everyone is empowered to contribute. That's why we're committed to growing an inclusive workforce that promotes opportunities for all.

Oracle careers open the door to global opportunities where work-life balance flourishes. We offer competitive benefits based on parity and consistency and support our people with flexible medical, life insurance, and retirement options. We also encourage employees to give back to their communities through our volunteer programs.

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Oracle is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability and protected veterans' status, or any other characteristic protected by law. Oracle will consider for employment qualified applicants with arrest and conviction records pursuant to applicable law.