Clinical Appeals Specialist II

4 weeks ago


Antioch, United States Community Health System Full time

Job Description

Essential Duties and Responsibilities: include the following. Other duties may be assigned.

* File medical necessity and level of care appeals using InterQual and CMS guidelines as needed.
* Monitor clinical appeal processes for issues and trends and provide guidance and feedback to related departments as needed.
* Track and manage clinical denials using current tools (manuals, training programs).
* Identify patterns and trends in denials; communicate to appropriate persons.
* Maintain documentation regarding all payor resources regarding denials and appeals processes.
* Understand and apply CHS 10-Step Appeal Process for denied claims.
* Know medical necessity criteria for outpatient testing and procedures.
* Follow and enforce accepted safety practices for patients and the hospital. Report safety hazards and initiate appropriate action. Participate in safety instructional programs.
* Observe excellent customer service skills when dealing with patients, families and/or significant others, outside vendors, coworkers, and physicians.
* Provide education to staff as appropriate.
* Document all actions accordingly by documentation standards within Artiva, HMS and other business office systems as required.
* Be familiar with policy and procedure manuals and other reference materials.
* Ensure confidentiality of all patient accounts by following HIPAA guidelines
* Perform additional duties as assigned or requested.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Knowledge/Abilities:

Required

* Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures.
* Understanding of the revenue cycle and the responsibility and goals of each area
* Must be able to interact with all levels of hospital administration, physicians and other healthcare team members they impact the revenue cycle
* Must be able to follow directions and perform work according to departmental standards and must be able to function effectively under stressful conditions.
* Excellent writing and communications skills as well as effective organizational skills a must.\

Reasoning Ability: Ability to define problems, collect data, validate data, establish facts, and draw valid conclusions

Computer Skills:

Required

* Microsoft office

Education/Experience:

Required

* Must have diploma/degree from an accredited school of nursing
* 5 years of clinical nursing experience.
* Certificates and Licenses: Current RN license to practice in state

Preferred

* Utilization review and/or case management experience



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