Clinical Appeals Coordinator

University of Mississippi Medical Center•Clinton, MS

1d•Onsite

About The Position

To provide coordination and support of university hospitals and health system /university physician billing process and the denials and appeals review process. To participate in the review, evaluation, monitoring, measuring and adjustment of all patient care payments denials and associated claims; participates in the development of risk minimization appeals program. Conducts research including departmental interviews/communication for verification of denial, clinical review of the denial, and conducts a reporting process for quality improvement initiatives to prevent future issues.

Requirements

Valid RN license.
Knowledge and understanding of clinical organization structure, workflow, and operating procedures.
Skill in the use of personal computers and related software applications.
Ability to manage multiple priorities under time constraints; ability to analyze and solve problems.
Understanding cost and quality issues.
Verbal and written communication skills.
Interpersonal skills to interact with a wide range of constituencies.
Decision-making skills.

Nice To Haves

Utilization review and/or case management is preferred.

Responsibilities

Reviews patient medical records and collects data for billing and/or appeals process management, analysis, studies, and monitoring.
Communicates with insurer to determine if payments/denials are appropriate.
Collect, review and perform timely appeals on medical necessity denials and/or authorization denials.
Conducts clinical research and analyses and prepares reports as required; anticipates and identifies issues in order to develop strategies and solutions in the payment and appeals process.
Assist as needed with chart audits, reviewing and comparing the medical records against the patient's itemized bill to ensure complete and accurate revenue integrity.
Participates in planning system-wide measurement initiatives with respect to assessment and management of accounts to determine patterns and trends of payment and/or denials and facilitates communication to improve performance and educate management.
Assists in the review of clinical practice for quality improvement and loss control; recommends appropriate corrective action; reviews for consistency, adherence to policy and comparative level of care in all settings; inputs data and prepares reports.
Communicates with clinical and non-clinical staff all findings.
Communicates and negotiates with external stakeholders.
Maintains an understanding of current TJC standards pertaining to denial and appeals management; assists the university hospitals and health system to maintain compliance with regulatory standards, federal and local as it pertains to denial of claims.
Provides timely internal/external customer service in a cooperative, professional, and respectful manner.