Clinical Appeals Consultant PRN

Intermountain Health•Lake Park, IA

3d•$40 - $61

About The Position

Uses nationally recognized, evidence-based utilization criteria to review medical records and perform clinical assessments for patient accounts to be appropriately appealed. Attends and testifies at hearings on behalf of the patient and Intermountain Healthcare when insurance companies are disputing the medical necessity of the admission. Reports to the Director of Audit and Appeals in the Revenue Integrity Department. ESSENTIAL DUTIES AND RESPONSIBILITIES 1. Uses nationally recognized evidence-based utilization review criteria to assess and write up clinical reviews for insurance audits and governmental insurance appeals using supporting documentation. 2. Assesses the appropriateness of clinical appeal requests by using payer policies and Federal and State regulations. 3. Works with Physician Advisors to obtain clinical support for appeals if needed. 4. Collaborates with Care Management, Utilization Review, Physician Advisors, Revenue Integrity, Compliance, Legal Counsel and the RCO teams to prepare appeals. 5. Identifies trends and works with the appropriate multidisciplinary teams to improve denial management, documentation and appeals processes. 6. Supports and works with legal counsel to prepare for Administrative Law Judge hearings as part of the appeal process. Please note that a video interview through Microsoft Teams will be required as well as potential onsite interviews and meetings. We are committed to offering flexible work options where approved and stated in the job posting. However, we are currently not considering candidates who reside or plan to reside in the following states: California, Connecticut, Hawaii, Illinois, New York, Pennsylvania, Rhode Island, Vermont, Washington. At Intermountain Health, we use the artificial intelligence ("AI") platform, HiredScore to improve your job application experience. HiredScore helps match your skills and experiences to the best jobs for you. While HiredScore assists in reviewing applications, all final decisions are made by Intermountain personnel to ensure fairness. We protect your privacy and follow strict data protection rules. Your information is safe and used only for recruitment. Thank you for considering a career with us and experiencing our AI-enhanced recruitment process. All positions subject to close without notice. Headquartered in Utah with locations in six primary states and additional operations across the western U.S., Intermountain Health is a nonprofit system of 34 hospitals, 400+ clinics, a medical group of more than 4,800 employed physicians and advanced care providers, a health plan division called Select Health with more than one million members, and other health services. Helping people live the healthiest lives possible, Intermountain is widely recognized as a leader in clinical quality improvement and efficient healthcare delivery. Join our world-class team and embark on a career filled with opportunities, strength, innovation, and fulfillment. To find out more about us, head to our career site here. Sign up for job alerts! Click ‘sign in’ at the top right corner, create a candidate account, and when we have opportunities that meet your interests, you will receive an email with the job details. Intermountain Health strives to make the application process accessible to all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact 1-800-843-7820 or email [email protected]. This contact information is for accommodation requests only and cannot be used to inquire about the status of applications. Introduce yourself to our Talent Acquisition team and we will get in touch if there is a role that seems like a good match. Intermountain Health’s PEAK program supports caregivers in the pursuit of their education goals and career aspirations by providing up-front tuition coverage paid directly to the academic institution. The program offers 100+ learning options to choose from, including undergraduate studies, high school diplomas, and professional skills and certificates. Caregivers are eligible to participate in PEAK on day 1 of employment. Learn more. The primary intent of this job description is to set a fair and equitable rate of pay for this classification. Only those key duties necessary for proper job evaluation and/or labor market analysis have been included. Other duties may be assigned by the supervisor. All positions subject to close without notice. Thanks for your interest in continuing your career with our team!

Requirements

Graduate of an accredited school of nursing is required (Associates or Bachelor’s degree) is required
Current valid RN License is required
Three (3) years experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting required.

Nice To Haves

Bachelor’s degree (BSN) is preferred.
Five (5) years experience in utilization review or care management, hospital insurance billing, third party claim audits or auditing in a healthcare setting required

Responsibilities

Uses nationally recognized evidence-based utilization review criteria to assess and write up clinical reviews for insurance audits and governmental insurance appeals using supporting documentation.
Assesses the appropriateness of clinical appeal requests by using payer policies and Federal and State regulations.
Works with Physician Advisors to obtain clinical support for appeals if needed.
Collaborates with Care Management, Utilization Review, Physician Advisors, Revenue Integrity, Compliance, Legal Counsel and the RCO teams to prepare appeals.
Identifies trends and works with the appropriate multidisciplinary teams to improve denial management, documentation and appeals processes.
Supports and works with legal counsel to prepare for Administrative Law Judge hearings as part of the appeal process.

Benefits

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
Intermountain Health’s PEAK program supports caregivers in the pursuit of their education goals and career aspirations by providing up-front tuition coverage paid directly to the academic institution. The program offers 100+ learning options to choose from, including undergraduate studies, high school diplomas, and professional skills and certificates. Caregivers are eligible to participate in PEAK on day 1 of employment. Learn more.

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