Clinical Denials Appeals

Job description:

Key Responsibilities:

Denials and Appeals Management:

• Review and evaluate denied claims including payer policies and clinical documentation
• Submit retro-authorizations in response to authorization denials
• Conduct medical necessity reviews and prepare supporting clinical summaries
• Write and submit detailed well-supported appeals based on clinical documentation and payer guidelines
• Track document and follow up on all appeals through resolution
• Maintain accurate and timely communication with payers and internal stakeholders
• Perform research to support appeals and stay updated on payer policies and best practices

Tracking Reporting and Trends:

• Monitor and analyze denial trends and root causes
• Escalate patterns and issues to management with recommendations
• Assist in preparing and maintaining reports related to denials and appeals
• Collaborate with teams to improve processes and reduce A/R

Compliance and Continuous Improvement:

• Ensure compliance with HIPAA company policies and regulatory requirements
• Identify and report billing discrepancies and compliance risks
• Participate in process improvement and system enhancement initiatives
• Engage in ongoing professional development and training

Qualifications:

Required:

• At least 1 year of clinical appeals writing experience
• 35 years of acute care clinical experience in a hospital setting (23 years if ICU)
• Bachelor of Science in Nursing (BSN)
• Active PHRN or USRN license
• Strong knowledge of U.S. healthcare systems insurance regulations and RCM processes
• Proficiency in InterQual or MCG clinical guidelines
• Experience with EMR systems such as Epic Cerner or Meditech
• Excellent verbal and written English communication skills (minimum CEFR B2)