Job Description

Position Summary

The Clinical Appeals - Author performs appeals and denials management and represents the hospital where claims were denied by either governmental contractors or commercial payers. Completes comprehensive reviews of clinical documentation to determine if an appeal is warranted. Writes compelling clinically relevant letter that includes payer guidelines to support the medical necessity for the stay to be paid at the level that was billed. Handles audit-related correspondence and other administrative duties as required.

Required Qualifications

• Medical Graduate, Physician Assistant or Registered Nurse (Current CA License)
• Ability to multitask and maintain a work pace appropriate to workload
• Must demonstrate customer service skills appropriate to the job
• Excellent written and verbal communication skills in English
• Ability to effectively communicate with staff, including physicians, in a clear and concise manner
• Computer literacy and proficiency

Preferred Qualifications

• Knowledge of third-party payer regulations
• One (1) year of previous appeals/denials experience
• Knowledge in areas such as InterQual Level of Care Criteria and Milliman Criteria

Physical Requirements

These are requirements normally expected to perform regular job duties. Reasonable accommodations may be made in compliance with the Americans with Disabilities Act of 1990, and applicable, state and local law, to enable individuals with disabilities to perform the essential functions. Incumbent must be able to successfully perform all of the essential functions of the job with or without reasonable accommodation.

• Standing - Frequently
• Walking - Frequently
• Sitting - Frequently
• Reaching with Hands and Arms - Occasionally
• Climb or Balance - Occasionally
• Stooping, Kneeling, Crouching, or Crawling - Occasionally
• Talking - Frequently
• Hearing - Constantly
• Seeing - Constantly
• Performing repetitive motions with arms or hands - Frequently
• Lifting, carrying, pushing or pulling up to 10 lbs - Constantly
• Lifting, carrying, pushing or pulling up to 25 lbs - Occasionally
• Lifting, carrying, pushing or pulling up to 50 lbs - None
• Lifting, carrying, pushing, or pulling greater than 50 lbs - None
• Driving - Occasionally

Essential Job Functions / Major Areas of Responsibility

The essential functions below are not intended to be an exhaustive list of all duties that may be assigned to this position, nor does it restrict the duties which may be assigned to this position if such duties reasonably relate to the position.

Reads, understands and abstracts information from patient medical records in electronic and scanned paper formats within an EMR, meeting all department productivity goals, for identified payor populations as directed.

Utilizes clinical and regulatory knowledge and skills as well as knowledge of payer requirements to determine why cases are denied. Identifies risk factors, comorbidities and adverse events to determine if payer denial was justified and an appeal is required.

Utilizes pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments. Prepares convincing appeal arguments, using pre-existing payer criteria sets and/or clinical evidence from existing library of clinical references.

Performs duties in accordance with the ethical and legal compliance standards as set by hospital policies and procedures, and all regulatory agencies, including State and Federal. Maintains strictest confidentiality of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

Researches medical literature and evidence based medical publications to support the level of care provided.

Pay Rate: Min - $77,020 l Max - $102,975

Job Listing ID:1756172

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