Clinical Audit and Appeals Specialist

3 weeks ago


New Orleans, Louisiana, United States LCMC Health Full time

Job Summary

The Clinical Audit and Appeals Specialist plays a critical role in ensuring accurate reimbursement for our patients. Reporting to the Audit and Appeals Supervisor, this position is responsible for managing payer denials, conducting retrospective analytical reviews, and exercising discretion and independent judgment when completing medical record quality audits.

Key Responsibilities

  • Manage payer denials by conducting comprehensive analytical reviews of clinical documentation to determine if an appeal is warranted in a timely manner.
  • Exercise discretion and independent judgment when completing medical record quality audits of clinical validation documentation and prepare appeal arguments in conjunction with the appropriate department.
  • Research and analyze RRLs for government and third-party payer denials related to DRG Assignment, Medical Necessity, Level of Care, and Clinical Authorizations.
  • Collaborate with Compliance, Case Management, Coding, Patient Access, Managed Care Contracting, Central Business Office, Health Information Management, Finance, and Clinical departments to resolve Audit and Appeal trends and issues.

Requirements

  • 5-8 years of experience in Healthcare finance, revenue cycle management, patient accounting, and physician billing, coding, and documentation.
  • Bachelor's Degree in Healthcare (LCMC).
  • Certification as a Certified Professional Coder-Hospital, Certified Professional Coder, Certified Coding Specialist, or Certified Coding Specialist - Physician-based.

Skills and Abilities

  • Knowledge of accurate sources for updating all applicable code sets (CPT/HCPCS, ICD-10, etc.) and associated edits such as NCCI.
  • Understanding of multiple reimbursement systems, including IPPS, OPPS, and Managed Care.
  • Excellent oral, written, and interpersonal communication skills.
  • Ability to interpret and implement regulatory standards.

About LCMC Health

LCMC Health is a community-driven healthcare organization that values authenticity, originality, equity, inclusion, and a little 'come on in' attitude. We celebrate our NOLA roots and strive to bring the best possible care to every person and parish in Louisiana and beyond.



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