Clinical Appeals Specialist | PAM Health Corporate

PAM Health Corporate Office•Enola, PA

3d•Remote

About The Position

The Clinical Appeals Specialist is responsible for assisting the Corporate Director of Appeals Management (hereafter known as “Director”) by conducting a comprehensive analytic review of clinical documentation and complete the appeal process. The Clinical Appeals Specialist will write sound, compelling letters to support the appeal. They may also attend Administrative Law Judge hearings, handle audit related correspondence and other administrative duties as required. This is an exempt position.

Requirements

Five years’ experience as a clinical nurse in an acute care setting.
Current state-issued RN license.
Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse in an acute care setting.
Knowledge of regulatory and payer requirements for reimbursement and reason(s) for denials by auditors.
Knowledge in areas such as InterQual Level of Care and Milliman & Robertson criteria.
Ability to travel as required.

Nice To Haves

Having at least two to three years of experience in case management, discharge planning, and/or utilization review is preferred.
Knowledge of third party payer regulations related to utilization and quality review is preferred.
Knowledge of MAC, RAC, ZPIC denials and process.

Responsibilities

Review patient medical records and utilize clinical and regulatory knowledge and skills, as well as, knowledge of payer requirements to determine why cases/claims are denied and complete an appeal.
Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments.
Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory guidelines to prepare the response to the payer in an effort to overturn the denial in a professional and concise manner.
Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory guidelines to prepare for an Administrative Law Judge hearing and participate in hearings by providing testimony, as necessary.
Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Actively seek out opportunities for appeal by reviewing all insurance denials within assigned region.
Prepare data and analytics and share with the Director and Executive Team and provide feedback to hospitals regarding trends in denied claims.
Discuss documentation-related and level of care decisions with hospitals, independently, as required.
Have the ability to proficiently read, understand and communicate in writing abstract information from patient medical records in a professional manner. Demonstrates excellent written communication. Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; presents numerical data effectively; able to read and interpret written information
Ensure compliance with HIPAA regulations, including confidentiality, as required.
Demonstrates excellent written communication. Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; presents numerical data effectively; able to read and interpret written information.
Other duties as assigned.
Audit selected medical records to determine compliance with CMS guidelines and regulations. Coordinate with hospitals to correct any deficiencies prior to submission of records to auditors. Coordinate with government auditors to provide additional information as needed and set up educational sessions with hospitals following completion of audits. Maintain all required documentation related to assigned audits.