Clinical Denial QA

Performs advanced level work related to clinical denial management. The individual is responsible for managing claim denials related to referral, authorizations, notifications, non-coverage, medical necessity, and others as assigned.

Performs advanced level work related to clinical denial management. The individual is responsible for managing claim denials related to referral, authorizations, notifications, non-coverage, medical necessity, and others as assigned.

The Clinical Denial Specialist conducts comprehensive reviews of the claim denial, account/guarantor notes associated with the denial, and the medical record to make determinations if a revised claim needs to be submitted, if a retro authorization needs to be obtained, if a written appeal is needed, or if no action is .

The Clinical Denial Specialist conducts comprehensive reviews of the claim denial, account/guarantor notes associated with the denial, and the medical record to make determinations if a revised claim needs to be submitted, if a retro authorization needs to be obtained, if a written appeal is needed, or if no action is .

The Clinical Denial Specialist writes and submits professionally written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. Appeals are submitted timely and tracked through final outcome.

The Clinical Denial Specialist writes and submits professionally written appeals which include compelling arguments based on clinical documentation, third-party payer medical policies, and contract language. Appeals are submitted timely and tracked through final outcome.

the Quality Assurance (QA) Specialist is responsible in ensuring accuracy of information and quality of delivery by monitoring, auditing,reviewing, analyzing, documenting work processes that further improves clinical operations standards. Performs quality audits, validates resultsand communicates recommendation among responsible departments. Participates in...

Elsevier is singularly focused on helping healthcare professionals improve clinical outcomes through evidence-based care. Our products and services are designed to help caregivers, professionals, and students improve practice, encourage broad and deep adoption of evidence-based practice, and promote a culture of quality within health care organizations.We...

the Quality Assurance (QA) Specialist is responsible in ensuring accuracy of information and quality of delivery by monitoring, auditing, reviewing, analyzing, documenting work processes that further improves clinical operations standards. Performs quality audits, validates results and communicates recommendation among responsible departments. Participates...

the Quality Assurance (QA) Specialist is responsible in ensuring accuracy of information and quality of delivery by monitoring, auditing, reviewing, analyzing, documenting work processes that further improves clinical operations standards. Performs quality audits, validates results and communicates recommendation among responsible departments. Participates...

Shift Schedule: NightshiftWork Setup: HybridSummary:The clinical support specialist (CSS) provides administrative support to clinical staff within Member Health. The CSS adheres to established customer service standards of accuracy, courtesy, and professionalism. This position supports timely determination turnaround times on all prior authorization requests...

Nezda is currently looking for Utilization Review Nurse (USRN) - WFH candidates.Qualifications: Active USRN and PHRN License With at least 1 Year Clinical or Hospital ExperienceJob Description: Reviews service requests to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits and contracts. Responsible for conducting...

Job Description: We are currently seeking a passionate and detail-oriented Quality Assurance Nurse (QA Nurse) to join our team. The QA Nurse will play a critical role in ensuring that our healthcare services meet the highest standards of quality and patient safety. As a Quality Assurance Nurse, you will be responsible for monitoring and improving the quality...

This role is an open-end contract position with a hybrid work setup. Please apply only if you are amenable to these terms.The Quality Improvement Specialist is responsible for ensuring the quality and compliance of utilization management processes within the organizations. They will also ensure quality and effectiveness as well as compliance with all the...

In this Role you will be Responsible ForCommunicate with contracted and non-contracted Providers by providing information and assistance as appropriate.Assist Providers with interpreting Member eligibility and benefit informationAssist with general question about the existing Programs and Member benefits.Assist with direction on the available Provider...

The AR Specialist II is responsible for billing, re-billing, post-payment/account follow-up, and grievance preparation of assigned. Client Hospital Accounts Receivable. Working at a Client site or in a Centralized location, responsibilities may include account maintenance of specialized or multiple payers including state and federal government programs,...

Job PurposeProvide leadership and guidance to off-shore RCM Partners and their teams reviewing processes and providing recommendations for improvement of operations working towards our combined operational goal to meet or exceed national AR KPI benchmarks and client specific KPIâs. Help support project work for all functions with offshore and ensure they...

Job DescriptionWe have an excellent new opportunity fora Medical Device Lead Auditor to join our global organization.The successful candidate will be responsible for planning and conducting audits against the manufacturing of medical devices, in accordance with ISO 13485, MDD 93/42/EEC, and MDSAP standards, enabling the delivery of assessment and...