Clinical Denials Clinician
3 days ago
SUMMARY
The Clinical Denials Clinician of AR Management is responsible for recovering revenue through a.) intelligent and ethical investigation of disputed/denied clinical claims, b.) verifying eligibility for clinical review, and c.) preparation and documentation of appeals based on industry-accepted criteria. He / She is also relied on when it comes to synergizing with the Denials team on processes and best practices.
JOB DUTIES & RESPONSIBILITIES
Serves as a resource to non-clinical personnelProvides Clinical Resource Center (CRC) leadership with sound solutions related to process improvementAssists in development of policies and procedures as business needs dictateAssists Law Department with any medical necessity reviews as capacity allows up to and including attending mediation hearings, other litigation forums, etc.Performs retrospective (post-discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.Constructs and documents a succinct and fact-based clinical case to support appeal utilizing appropriate module of evidenced-based medicine guidelines (InterQual criteria (Acute, Procedures, etc), MCG Guidelines, or Payer Specific Guidelines). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.QUALIFICATIONSRequired:
Minimum of 1-year Medical Necessity Appeals Writing experience in a provider or payor settingMedical-surgical/critical care experience; managed care payor experience either in Utilization Review, Case Management or Appeal; Minimum of 1-year recent acute care experience in a facility environmentPreferably possess a valid nursing license, advanced medical degree such as Occupational Therapy (O.T.), Physical Therapy (P,T.) or Medical Doctor (M.D.) with previous appeal writing experience.Current, valid RN licensure; Certified Case Manager (CCM) or Certified Professional in Utilization Review/Utilization Management/Healthcare Management (CPUR , CPUM, or CPHM)Working Conditions:Amenable to work in BGC, TaguigWilling to work in a dayshift scheduleCompany Benefits:Competitive SalaryHMO on day 1 plus 1 dependent; Additional 2 HMO dependents upon regularizationGroup life insurancePTO CreditsAnnual AppraisalAnnual Performance Bonus-
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