[Hiring] Clinical Appeals Analyst @Revecore

Role Description

Primarily responsible for thorough review of claim denials from managed care and other insurance carriers and denial management activities related to the collection of denied hospital claims.

• Handle verbal and/or written appeals requiring clinical input or interpretation.
• Identify coding or clinical documentation issues and work to correct and overturn denials.
• Review and perform retrospective reviews, investigate and appeal all clinical level denials such as not medically necessary inpatient stays or levels of care, authorization or other denial issues.
• Audit Medical Records to retrieve clinical information for appeal, prepare appeal correspondence.
• Utilize online payor portals.
• Review and process correspondence including approvals and denials/adjustments, demand letters and results from various levels of appeals.
• Work with team to monitor, track, trend and coordinate denial resolution with payers.
• Communicate with all parties in a professional manner to alert of specific problem issues.
• Perform other duties as assigned.

Qualifications

• Working knowledge of Microsoft Office suite (Word, Excel).
• Moderate computer proficiency.
• Working knowledge of the revenue cycle.
• Ability to read and interpret an extensive variety of documents such as contracts, claims, instructions, policies and procedures in written (in English) and diagram form.
• Ability to write routine correspondence (in English).
• Ability to define problems, collect data, establish facts and draw valid conclusions.
• Strong customer service orientation.
• Excellent interpersonal and communication skills.
• Commitment to company values.

Requirements

• Licensed as an LPN (must possess and maintain a current state nursing license).
• At least 3 years of experience as a Case Manager or equivalent is desired.
• At least 1 year experience with medical necessity appeals at all levels is preferred.
• Bachelor's degree desirable, but equivalent job experience will be considered.
• Experience using standardized clinical guidelines; InterQual experience preferred.

Benefits

• Paid training and incentive plans.
• Medical, dental, vision, and life insurance benefits available from the first day of employment.
• Excellent work/life balance.
• Employee Resource Groups build community and foster a culture of belonging and inclusion.
• 401(k) contributions matched.
• Career growth opportunities.
• 12 paid holidays and generous paid time off.

Work at Home Requirements

• A quiet, distraction-free environment to work from in your home.
• A reliable hard-wired private internet connection that is not supplied via cellular data or hotspot is required.
• Home internet with speeds >20 Mbps for downloads and >10 Mbps for uploads.
• The workspace area accommodates all workstation equipment, related materials, and provides adequate surface area to be productive.