Specialist, Clinical Appeals

Ovation Healthcare • Crest, CA

21h • Remote

About The Position

The Specialist, Clinical Appeals performs comprehensive reviews of denied claims, focusing on clinical issues such as medical necessity, level of care, non-covered services, and authorization-related denials. This role involves thorough analysis of patient medical records, payer medical policies, and relevant medical necessity criteria to build robust clinical cases for appeal. The specialist will independently write professional, persuasive appeal letters, leveraging generative AI tools for efficiency, and ensure all appeals are submitted accurately and tracked to resolution. Collaboration with Payer Contract Specialists, Certified Coders, and Revenue Recovery Specialists is crucial for a coordinated approach. The position also involves identifying and reporting emerging denial trends to support root cause analysis and the development of denial prevention strategies, as well as assisting in creating and maintaining standardized appeal letter templates.

Requirements

• Strong clinical acumen with the ability to critically analyze medical records and justify the medical necessity of services rendered.
• Exceptional written communication skills, with the ability to craft clear, concise, and persuasive arguments.
• Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.
• Comfortable navigating and troubleshooting various applications, including Microsoft Office Suite, data management systems, and virtual collaboration tools.
• Highly organized, self-motivated, and able to work independently to manage a caseload and meet deadlines.
• Familiarity with medical billing, coding principles (ICD-10, CPT), and payer reimbursement methodologies.
• Active and unrestricted Registered Nurse (RN) license.
• Previous experience in denial management or clinical appeals role.
• Minimum of 2-3 years of clinical experience in a hospital or healthcare setting.

Nice To Haves

• Bachelor of Science in Nursing (BSN) preferred.
• Experience in Case Management, Utilization Review, or Clinical Documentation Improvement (CDI) is highly desirable.

Responsibilities

• Perform comprehensive reviews of denied claims, focusing on clinical issues such as medical necessity, level of care, non-covered services, and authorization-related denials.
• Conduct thorough analysis of patient medical records, payer medical policies, and relevant medical necessity criteria (e.g., InterQual, Milliman) to build a robust clinical case for appeal.
• Identify gaps in clinical documentation and collaborate with other team members to gather the necessary supporting evidence for a successful appeal.
• Independently write professional, persuasive appeal letters that present a compelling clinical argument for payment.
• Leverage generative AI tools to assist in drafting initial appeal letters, increasing efficiency and allowing focus on the most complex cases.
• Ensure all appeals are submitted accurately, within payer-specific timelines, and tracked through to final resolution in the Pulse platform.
• Work closely with the Payer Contract Specialist, Certified Coders, and Revenue Recovery Specialists to ensure a holistic and coordinated approach to each appeal.
• Identify and report emerging denial trends to team leadership to support root cause analysis and the development of denial prevention strategies.
• Assist in creating and maintaining standardized appeal letter templates for various denial types and payers to improve team efficiency.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level