Yale New Haven Health

The Clinical Triage Nurse performs telephonic triage for a diverse patient population using clinical protocols to direct them to the appropriate level of care, aiming for one-call resolution when applicable. Responsibilities also include communicating with providers and families, following up with patients, maintaining documentation, and coaching other triage staff.

The specialist manages medical denials by reviewing clinical documentation, writing compelling appeal arguments based on payer policies, and submitting appeals promptly to reduce financial liability and recover lost revenue. This role also involves identifying and resolving denial trends, handling audit/compliance responsibilities, and collaborating with internal teams and payers to expedite reimbursement.

The advisor serves as the first point of contact for employee inquiries regarding HR benefits, practices, and policies, aiming for first-contact resolution while owning the case management process from opening to closing cases according to SLAs. Responsibilities also include coordinating with subject matter experts, monitoring phone coverage, and educating employees on self-service tools.