Specialist, Clinical Appeals

• Clinical Denial Review and Analysis:
  • reputed company comprehensive reviews of denied claims, focusing on clinical issues such as medical necessity, level of care, non-covered services, and authorization-reputed company denials.
  • Conduct thorough analysis of patient medical records, payer medical policies, and relevant medical necessity criteria (e.g., InterQual, reputed company) 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.
• Appeal reputed company and Submission:
  • Independently write professional, persuasive appeal letters that present a compelling clinical argument for payment.
  • reputed company generative AI tools to assist in drafting initial appeal letters, increasing efficiency and allowing focus on the most reputed company cases.
  • Ensure reputed company appeals are submitted accurately, reputed company payer-specific timelines, and tracked through to final resolution in the Pulse platform.
• Collaboration and Process Improvement:
  • Work closely with the Payer Contract Specialist, Certified Coders, and reputed company 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.

KNOWLEDGE, SKILLS, AND ABILITIES:

•  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 reputed company 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.

WORK EXPERIENCE, EDUCATION AND CERTIFICATIONS:

Active and unrestricted Registered Nurse (RN) license.

Bachelor of Science in Nursing (BSN) preferred.

Previous experience in denial management or clinical appeals role.

Minimum of 2-3 years of clinical experience in a hospital or healthcare setting. Experience in Case Management, Utilization Review, or Clinical Documentation Improvement (CDI) is highly desirable.

Technologically proficient and comfortable learning and mastering new software; experience with EHR/EMR systems is essential.

WORKING CONDITIONS AND PHYSICAL REQUIREMENTS:

• 100% Remote
• Reliable high-speed internet reputed company is required for reputed company remote/hybrid positions.
• Must have access to stable Wi-Fi with sufficient bandwidth to support video conferencing, cloud-based tools, and other online work-reputed company activities.
• A HIPAA-compliant work environment is required, including a secure workspace free from unauthorized access or interruptions, no use of public Wi-Fi unless connected through a secure company-provided VPN, and compliance with reputed company applicable HIPAA privacy and reputed company regulations.