Clinical Utilization Review and Appeals Coordinator - FT - Days - Care Coordination-Patient Support @ MV
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About The Position
The Clinical Utilization Review and Appeals Coordinator combines clinical, business and regulatory knowledge and skill to reduce financial risk and exposure caused by concurrent and retrospective denial of payment for services provided. Reviews and validates admission status of surgical admissions, verifies procedure against the Inpatient Only List and Inter-Qual Criteria, educates Physicians and facilitates obtaining the correct admission status, ensure that the appropriate notification letters are issued, reviews concurrent denials and provides insurance reviews, serves as an Inter-Qual resource to staff, provides oversight and compliance of the Observation status process, ensures compliance with the 2-midnight rule. Pursues, analyzes and remains up to date on data regarding all medical necessity denials. Collaborates with physicians, case managers, Hospital Billing Office staff and payers to appeal denials. Insures a functional denial appeals process, including measuring denial and appeal activity, monitoring for patterns and trends, and reporting the outcomes of these activities as requested. Serves as the central point person for all commercial and government claim recovery activities providing efficient management of work flow related to MediCal, commercial denial/appeal and Recovery Audit activities. Provides guidance, support and oversight to ensure effective management of the audit response process. Facilitates all aspects of the denial/appeal process which include maintaining database, tracking and trending denials, and reporting process outcomes.
