Clinical Appeals Analyst

Revecore

12d • Remote

About The Position

Primarily responsible for thorough review of claim denials from managed care and other insurance carriers and denial management activities related to the collection of denied hospital claims. Handle verbal and/or written appeals requiring clinical input or interpretation, as well as identify coding or clinical documentation issues and work to correct and overturn denials.

Requirements

• Working knowledge of Microsoft Office suite (Word, Excel)
• Moderate computer proficiency
• Working knowledge of the revenue cycle
• Ability to read and interpret an extensive variety of documents such as contracts, claims, instructions, policies and procedures in written (in English) and diagram form
• Ability to write routine correspondence (in English)
• Ability to define problems, collect data, establish facts and draw valid conclusions
• Strong customer service orientation
• Excellent interpersonal and communication skills
• Commitment to company values
• Licensed as an RN or LPN (must possess and maintain a current state nursing license)
• At least 3 years of experience as a Case Manager or equivalent is desired
• At least 1 year experience with medical necessity appeals at all levels is preferred
• Bachelor's degree desirable, but equivalent job experience will be considered
• A quiet, distraction-free environment to work from in your home.
• A reliable hard-wired private internet connection that is not supplied via cellular data or hotspot is required.
• Home internet with speeds >20 Mbps for downloads and >10 Mbps for uploads.
• The workspace area accommodates all workstation equipment, related materials, and provides adequate surface area to be productive.

Nice To Haves

• Experience using standardized clinical guidelines; InterQual experience preferred

Responsibilities

• Review and perform retrospective reviews, investigates and appeals all clinical level denials such as not medically necessary inpatient stays or levels of care, authorization or other denial issues
• Audit Medical Records to retrieve clinical information for appeal, prepare appeal correspondence
• Utilize online payor portals
• Review and process correspondence including approvals and denials/adjustments, demand letters and results from various levels of appeals
• Working with team to monitor, track, trend and coordinate denial resolution with payers
• Communicates with all parties in a professional manner to alert of specific problem issues
• Performs other duties as assigned

Benefits

• We offer paid training and incentive plans
• Our medical, dental, vision, and life insurance benefits are available from the first day of employment
• We enjoy excellent work/life balance
• Our Employee Resource Groups build community and foster a culture of belonging and inclusion
• We match 401(k) contributions
• We offer career growth opportunities
• We celebrate 12 paid holidays and generous paid time off

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level