Medical Appeals Specialist II, Med Plaza II

UofL Health•Louisville, KY

1d•Onsite

About The Position

This position plays an integral role in the recovery of denied reimbursement for hospital services rendered to a patient by providing a comprehensive review of a members’ clinical information and comprising a verbal or written response depicting why the services were medically necessary. Team members will be responsible for the identification, mitigation, and prevention of clinical denials including medical necessity and authorization issues. Team members will manage complex patient accounts with precision and accuracy while analyzing medical records to formulate compelling clinical arguments. Efforts will apply to pre claim edits as well as pre- or post-payment audits from insurance carriers or designated third part vendors. Team members will interact as needed with internal customers to include but not limited to hospital staff, physicians and their offices, and other revenue cycle team members. This position will maintain reporting and collaborate with the Payor Relations and Contracting Department during contract negotiations and settlements on denial issues and payment variances impacting payment from third party payers for consideration.

Requirements

Licensed/certified healthcare professional, such as LPN, RN, OTR, or other clinical license (required).
3-5 years of clinical experience (required).
Active, unrestricted registered clinical license (required).
Knowledge of medical terminology.
Working knowledge of InterQual, Milliman Care Guidelines, and Coding Rules and Guidelines.
Critical thinking skills.
Strong oral and written communication skills.
Advanced Microsoft Office knowledge.
Ability to foresee projects from start to finish.
Must be able to communicate effectively in both verbal and written formats.
Ability to read and interpret documents, i.e. contracts, claims, instructions, policies, and procedures in written (in English) form.
Ability to think critically to define problems, collect data, and establish facts to execute sound financial decisions regarding patient account(s).
Ability to analyze and interpret information on electronic remittances / EOBs / EOPs.
Ability to analyze data, identify trends and implement improvements.
Moderate to advanced computer proficiency including knowledge of MS Excel, Word and Outlook
General computer knowledge and working with electronic filing systems.

Nice To Haves

Bachelor’s degree in clinical occupation, such as BSN (preferred).
Experience with appeals and/or denial processing (preferred).
Clinical nursing experience working in a hospital setting – ER, Critical Care, or Diagnostic Services (preferred).
CCM (certified case manager), CPUM (certified professional in utilization management) or other relevant certification (preferred).

Responsibilities

Prepare strong appeal letter(s) based on clinical documentation, evidence-based clinical guidelines, and knowledge using nationally accepted criteria, medical literature if applicable, healthcare statutes and payor requirements.
Denial issues may include: post-discharge medical necessity, DRG validations, retroactive prior authorizations, Recovery Audit Contractor (RAC) and other claim audits.
Utilizes clinical knowledge and defined standards of care to proactively identify inappropriate admit status based on evidence-based clinical guidelines, i.e. Milliman Clinical Guidelines (MCG) and InterQual Criteria.
Ensures clinical interventions are appropriate for the admitting diagnosis and reflects the standard of care as defined by the medical staff and health system.
Analyze medical records or other medical documentation to determine potential for appeal or validate services, tests, supplies, and drugs for accuracy related to the billed charges.
Communicates with physicians and multidisciplinary health system team members to effectively utilize all available resources to ensure a strong and efficient appeal is submitted.
Research commercial and governmental payor policies, regulations, and clinical abstracts related to claims payment to evaluate and appeal denied claims.
Perform timely follow-up on account appeals with understanding of patient accounting documents such as: UB04, Explanation of Benefits (EOB).
Perform retrospective authorization requests for services already performed as needed.
Supports billing staff by reviewing accounts before claim submission to prevent clinical denials.
Assist in tracking/maintaining quantitative and qualitative reviews for data trending, outcomes, and success rate of appeals.
Supports global denial prevention and mitigation efforts throughout the health system by attending denial prevention meetings and/or payer representative meetings.
Maintain compliance with all company policies, procedures, and standards of conduct.
Performs other duties as assigned.
Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.
Maintains confidentiality and protects sensitive data at all times.
Adheres to organizational and department specific safety standards and guidelines.
Works collaboratively and supports efforts of team members.
Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.