Clinical Appeal Denial Writer

Hudson Regional Hospital • Clifton, NJ

2d

About The Position

Manages and reviews clinical denial appeals to payers.

Requirements

• Clinical knowledge to denial appeals process.
• Knowledge of regulatory and payer requirements for reimbursement and reasons for denials by auditors.
• Outstanding organization skills.
• Excellent verbal and written communication skills.
• Proficient in Microsoft Office.
• The ability to quickly gain comfort with other software programs needed to perform the essential functions of the position.
• Thorough understanding of clinical processes and knowledge of billing, coding and Milliman Care Guideline (MCG) criteria.
• Minimum of 1 year Clinical Medical Necessity Appeals preparation.
• Active RN license in the state of NJ.

Nice To Haves

• Three years of experience in acute care utilization review is preferred.
• BSN preferred.

Responsibilities

• Coordinates appeal for clinical denials to managed care/insurance companies and governmental agencies.
• Writes clinical appeals and audits patient medical and billing records to determine documentation and items billing are appropriate.
• Follows through to ensure that audit adjustments are made and corrective actions are taken to address identified billing, charging, and documentation issues.
• Prepares first, second, and third level appeals utilizing relevant clinical information and professional standards and guidelines.
• Collaborate with each hospital physician advisors and Utilization/Case Managers.
• Performs other duties as assigned
• Possesses and consistently develops the ability to understand medical policies for commercial carriers to determine the medical necessity for audits.
• Remains current with all governmental regulations and policies related to audits including RAC and others. Maintains working knowledge of governmental regulations for billing purposes when performing audits.
• Proposes language changes because of denial reviews and observations.
• Obtains a thorough understanding of managed care contracts as part of appeal process.
• Collaborates with physicians and leadership to enhance denial management and improve clinical documentation improvement efforts.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees