Clinical Appeals Specialist
Clinical Appeals Specialist
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Job Description
The Clinical Appeals Specialist is responsible for managing client medical necessity denials for multiple service lines (Eating Disorder Treatment Substance Abuse Treatment and Mental Health Treatment) by conducting a
comprehensive analytic review of clinical documentation to determine if an appeal is warranted per state and Federal guidelines. Where warranted the Clinical Appeals Specialist will write sound compelling factual arguments. The Clinical Appeals Specialist will also handle auditrelated correspondence and other administrative duties as required.
**This is a fulltime remote opportunity**
Essential Job Functions:
Review patient medical records and utilize clinical and regulatory knowledge and skills as well as knowledge
of payer requirements to determine why cases are denied and whether an appeal is required.
Logs tracks and processes appeals and grievances. Conducts pertinent research in order to evaluate respond
to and close appeals. Builds case files for each grievance and ensures compliance with organizational and
regulatory guidelines.
Utilize preexisting criteria and other resources and clinical evidence to develop sound and wellsupported
appeal arguments.
Interact with Supervisors Manager Medical Directors Case Management Precertification Legal Member
Services and other departments in facilitating identification and resolution of grievances.
Prepare convincing appeal arguments using preexisting criteria sets and/or clinical evidence from existing
library of clinical references and/or regulatory arguments.
Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
Discuss documentationrelated and level of care decisions as required.
Proficiently read and understand abstract information from handwritten patient medical records.
Ensure compliance with HIPAA regulations to include confidentiality as required.
Responsible for compliance with all regulatory and department timelines.
Must be able to organize plan and implement the functions of Member Appeals and Grievances maintain
timelines and turnaround times to meet multiple requirements/regulations established by external regulating
bodies and applicable state and federal laws
Requires ability to understand and be compliant with State and Federal regulations.
Qualifications :
Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse or therapist. In addition having at least two to three years of experience in case management discharge planning and/or utilization review is preferred.
Knowledge of regulatory and payer requirements for reimbursement and reason(s) for denials by auditors.
Ability to critically evaluate and make decisions about whether appeals should be made based on reviews of patient medical records.
Skill in writing convincing appeals arguments that are sound and supported by evidence that is related to patients specific clinical attributes
Ability to use preexisting criteria sets and/or clinical evidence from an existing library of clinical references and/or regulatory arguments to support ones own clinical appeals arguments
Ability to search for supporting clinical evidence to support appeal arguments when there are not existing resources available
Demonstrated ability to prepare arguments for an Administrative Law Judge Hearing and participate in a hearing
Ability to proficiently read understand and abstract information from handwritten patient medical records are essential prerequisites.
Ability to work in a homebased environment and to work independently as an individual contributor and adapt quickly to changing priorities.
Maintains confidentiality of patient data and medical records in compliance with HIPAA regulations.
Ability to read evaluate and abstract important information from handwritten patient medical records.
Excellent oral and technical writing and typing skills.
Demonstrates flexibility with a willingness to learn and adapt to changes in regulations and taskrelated priorities.
Ability to successfully work independently and to adapt quickly to changing priorities and regulations. Excellent oral and technical
writing skills and the Ability to maintain confidentiality according to HIPAA regulations is required.
Not sure if you meet all the qualifications Apply anyway! To provide truly innovative care we need to have a diverse team around us. Thats why Discovery Behavioral Health is committed to creating an inclusive environment. If you find yourself meeting some but not all the above wed be happy to consider your application.
Additional Information :
We are proud to be an EEO employer M/F/D/V. We maintain a drugfree workplace and perform preemployment substance abuse testing. All qualified applicants will receive consideration for employment without regard to age race color religion sex or national origin.
For more information about our company benefits please visit us at Behavioral Health seeks to build a diverse staff that is reflective of the patients we serve and the communities where we work. DBH encourages multiple perspectives experiences and strives to hire and retain a diverse workforce.
Remote Work :
Yes
Employment Type :
Fulltime
Employment Type
Remote
