Coordinator-Clinical Appeals

Loma Linda University Health•San Bernardino, CA

1d•Onsite

About The Position

The Coordinator-Clinical Appeals is responsible for supporting the daily functions and operations of the Billing and Collections department by reviewing and appealing clinical denials and retro authorizations. This role interfaces with payors, Case Managers, the Insurance Verification department, Financial Counselors, PBO, and the Health Information Management department. The position involves reviewing medical records for medical necessity of admission, severity of illness, and intensity of service based on InterQual and Milliman Guidelines. Responsibilities include documenting retro authorization and denial/appeal efforts in appropriate systems, reviewing accounts for appropriate trauma and NICU charges when inconsistent, and composing appeal letters to payors when denials violate state/federal laws or lack sufficient information. The role also evaluates in-patient hospitalizations for delay of service and discharge, reviews findings and appeal letters with Denial Clinical Appeals Unit (CAU) Management, and participates in department quality improvement projects. These services may be provided for all LLUH facilities. Performs other duties as needed.

Requirements

Minimum three years of experience in utilization management, utilization review or managed care within a hospital or related healthcare facility required.
Knowledge of health plan and medical group contracts including Medi-Cal and Medicare.
Knowledge of InterQual and Milliman criteria for in-patient hospitalization.
Able to read; write legibly; speak in English with professional quality.
Able to use computer, printer, and software programs necessary to the position (e.g., Word, Excel, Outlook, PowerPoint).
Able to operate and troubleshoot basic office equipment required for the position.
Able to relate and communicate positively, effectively, and professionally with others.
Able to work calmly and respond courteously when under pressure.
Able to collaborate and accept direction.
Able to communicate effectively in English in person, in writing, and on the telephone.
Able to think critically.
Able to manage multiple assignments effectively.
Able to organize and prioritize workload.
Able to work well under pressure.
Able to problem solve.
Able to recall information with accuracy.
Able to pay close attention to detail.
Able to work independently with minimal supervision.
Able to distinguish colors as necessary.
Able to hear sufficiently for general conversation in person and on the telephone, and identify and distinguish various sounds associated with the workplace.
Able to see adequately to read computer screens, and written documents necessary to the position.
Basic Life Support (BLS) certification issued by the American Heart Association required.

Nice To Haves

Nationally recognized certification in Utilization Management, Utilization Review, Hospital Utilization, Managed Care or Health Care related area preferred.
California Vocational Nurse (LVN) license preferred.
Medical Terminology certification accepted in lieu of LVN license.

Responsibilities

Support the daily function and operations of the Billing and Collections department.
Review and appeal clinical denials and retro authorizations.
Interface with payors, Case Managers, Insurance Verification department, Financial Counselors, PBO, and Health Information Management department.
Review medical records for medical necessity of admission, severity of illness, and intensity of service based on InterQual and Milliman Guidelines.
Document in appropriate systems the results of retro authorization and denial or appeal efforts.
Review referred accounts for appropriate trauma charges, as well as NICU when requested, when charges are inconsistent.
Compose and send appeal letters to payor when denial is in violation of state and federal laws as well as due to lack of sufficient information sent to payor.
Evaluate and review in-patient hospitalizations for delay of service and delay of discharge.
Review all findings and appeal letters with Denial Clinical Appeals Unit (CAU) Management.
Participate in department quality improvement projects.
Perform other duties as needed.