Clinical Appeals Author (E)Summary:The Clinical Appeals - Author performs appeals and denials management and represents the hospital where claims were denied by either governmental contractors or commercial payers. Completes comprehensive reviews of clinical documentation to determine if an appeal is warranted. Writes compelling clinically relevant letter that includes payer guidelines to support the medical necessity for the stay to be paid at the level that was billed. Handles audit-related correspondence and other administrative duties as required.
Education/Licensure: Medical Graduate, Physician Assistant or Registered Nurse (Current RI License)
Experience:
- Knowledge of third-party payer regulations
- One (1) year of previous appeals/denials experience
- Knowledge in areas such as InterQual Level of Care Criteria and Milliman Criteria
Skills and Abilities:
- Ability to multitask and maintain a work pace appropriate to workload
- Must demonstrate customer service skills appropriate to the job
- Excellent written and verbal communication skills in English
- Ability to effectively communicate with staff, including physicians, in a clear and concise manner
- Computer literacy and proficiency
Working Conditions, Physical Environment and/or Safety Requirements:
Visual acuity and hand dexterity. Physical ability involves variety of body movements including stooping, bending,
kneeling, lifting, standing, walking, twisting, stretching and reaching. Physical ability involves pushing, pulling
and lifting more than 30 lbs.
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