Clinician, Denials Prevention - Remote

Duties & Responsibilities

• Maintain the integrity of information in each appeal produced
• Review a high volume of written appeals to ensure information is medically accurate
• Research payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing resulting in denials and delays in payment
• Make recommendations for workflow revisions to improve efficiency and reduce denials
• Present case studies and recommendations to clients and impacted stakeholders
• Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements; escalate potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership as appropriate
• Identify opportunities for process improvement and actively participate in process improvement initiatives, internally and externally

Qualifications

• Bachelor’s degree in a health-related field; 2 years of experience may be considered in lieu of a degree in addition to the required experience
• LPN or RN preferred
• Two years of recent experience in hospital case management, hospital prior authorization, or utilization management
• Experienced in medical chart review
• Claim-related appeal writing experience preferred
• Experience with medical and insurance terminology, CPT, ICD coding structures, and billing forms
• Experience with MCG and/or InterQual guidelines preferred
• Proficiency in Microsoft Office Suite
• Strong interpersonal skills, ability to communicate well at all levels of the organization
• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
• High level of integrity and dependability with a strong sense of urgency and results oriented
• Excellent written and verbal communication skills required
• Gracious and welcoming personality for customer service interaction