Medical Appeals Specialist II, Med Plaza II

Job Description

This position plays an integral role in the recovery of denied reimbursement for hospital services rendered to a patient by providing a comprehensive review of a member's clinical information and composing a verbal or written response depicting why the services were medically necessary. Team members will be responsible for the identification, mitigation, and prevention of clinical denials including medical necessity and authorization issues. Team members will manage complex patient accounts with precision and accuracy while analyzing medical records to formulate compelling clinical arguments. Efforts will apply to pre claim edits as well as pre- or post-payment audits from insurance carriers or designated third-party vendors.

• Interact as needed with internal customers to include but not limited to hospital staff, physicians and their offices, and other revenue cycle team members.
• Maintain reporting and collaborate with the Payor Relations and Contracting Department during contract negotiations and settlements on denial issues and payment variances impacting payment from third-party payers for consideration.

Essential Functions

• Prepare strong appeal letter(s) based on clinical documentation, evidence-based clinical guidelines, and knowledge using nationally accepted criteria, medical literature if applicable, healthcare statutes and payor requirements.
• Denial issues may include: post-discharge medical necessity, DRG validations, retroactive prior authorizations, Recovery Audit Contractor (RAC) and other claim audits.
• Utilizes clinical knowledge and defined standards of care to proactively identify inappropriate admit status based on evidence-based clinical guidelines, i.e. Milliman Clinical Guidelines (MCG) and InterQual Criteria.
• Ensures clinical interventions are appropriate for the admitting diagnosis and reflects the standard of care as defined by the medical staff and health system.
• Analyze medical records or other medical documentation to determine potential for appeal or validate services, tests, supplies, and drugs for accuracy related to the billed charges.
• Communicate with physicians and multidisciplinary health system team members to effectively utilize all available resources to ensure a strong and efficient appeal is submitted.

Shift Requirements

Shift Length (in hours): 8
# Shifts/Week: 5
Overtime Required: n/a (exempt position)
Other Functions: None listed
Additional Job Description

Job Requirements

• Education: Licensed/certified healthcare professional, such as LPN, RN, OTR, or other clinical license (required). Bachelor’s degree in clinical occupation, such as BSN (preferred).
• Experience: 3-5 years of clinical experience (required). Experience with appeals and/or denial processing (preferred). Clinical nursing experience working in a hospital setting – ER, Critical Care, or Diagnostic Services (preferred).
• Licensure: Active, unrestricted registered clinical license (required).
• Certification: CCM (certified case manager), CPUM (certified professional in utilization management) or other relevant certification (preferred).

Job Competency

• Knowledge of medical terminology.
• Working knowledge of InterQual, Milliman Care Guidelines, and Coding Rules and Guidelines.
• Critical thinking skills.
• Strong oral and written communication skills.
• Advanced Microsoft Office knowledge.

Additional Responsibilities

• Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.
• Maintains confidentiality and protects sensitive data at all times.
• Adheres to organizational and department specific safety standards and guidelines.
• Works collaboratively and supports efforts of team members.
• Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.

UofL Health Core Expectation

• Lives the values of honesty, integrity and compassion and demonstrates these values in their interactions with others and as they deliver excellent patient care by:
• Honoring and caring for the dignity of all persons in mind, body, and spirit.
• Ensuring the highest quality of care for those we serve.
• Working together as a team to achieve our goals.
• Improving continuously by listening, and asking for and responding to feedback.
• Seking new and better ways to meet the needs of those we serve.
• Using our resources wisely.
• Understanding how each of our roles contributes to the success of UofL Health.