Senior Clinical Documentation Specialist

2 weeks ago

Manila, National Capital Region, Philippines beBeeMedicalRecordsSpecialist Full time $60,000 - $85,000
Job Overview

The Medical Records Specialist plays a pivotal role in ensuring timely and accurate review of medical records, upholding compliance with regulatory standards.

Key Responsibilities
  • Conduct thorough case reviews for Medical Directors by researching appeals, analyzing relevant criteria, and evaluating the basis for appeal.
  • Promptly process and respond to appeals requests in accordance with regulatory requirements.
  • Collaborate with members, providers, facilities, and other departments regarding appeals requests, fostering effective communication to resolve issues.
  • Generate resolution communications and reports for members and providers, adhering to established policies and regulatory standards.
  • Work closely with leadership to enhance consistency, efficiency, and appropriateness of responses to all appeals requests.
  • Partner with interdepartmental teams to refine clinical appeals processes and procedures, leveraging industry best practices to prevent recurrences.
  • Maintain comprehensive knowledge of policies and procedures for appeals processing, specifically Medicare and medical necessity review.
  • Exercise sound judgment in non-routine appeals, navigating the appeal process while meeting contractual timeliness standards.
  • Accurately maintain files on individual appeals, gathering and reporting verbal and written member and provider appeals.
  • Review claim appeals for reconsideration and recommend approvals/denials based on determination level or prepare for medical review presentation.
Required Skills and Qualifications
  • 2-4 years of experience in processing appeals or utilization management.
  • RN - Registered Nurse – State required licensure and/or compact state licensure.
  • Strong understanding of utilization management processes.
  • Knowledge of NCQA, Medicare, and Medicaid regulations.
  • Excellent communication skills (demonstrate strong reading comprehension and writing skills).
  • Able to work independently with strong analytical skills.

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