[Hiring] Clinical Appeals Author @NOR Healthcare Systems

Role Description

The Clinical Appeals - Author performs appeals and denials management and represents the hospital where claims were denied by either governmental contractors or commercial payers. Responsibilities include:

• Completing comprehensive reviews of clinical documentation to determine if an appeal is warranted.
• Writing compelling clinically relevant letters that include payer guidelines to support the medical necessity for the stay to be paid at the level that was billed.
• Handling audit-related correspondence and other administrative duties as 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

Requirements

• 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

• 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

• 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 | Max - $102,975

Job Listing ID

1756172