Clinical Appeals Specialist

3 weeks ago


Urbana, Illinois, United States DirectEmployers Full time

Job Overview:

Clinical Appeals Specialist - Outpatient Healthcare Revenue Review Professional - Carle Health

Compensation:

$65,000 - $85,000 per year

Job Description:

As a Clinical Appeals Specialist with Carle Health, you will serve as an expert resource in outpatient clinical documentation review, establishing and managing clinical and prior authorization denial appeals for the Carle enterprise. You will represent Carle in clinical meetings and write appeals on outpatient accounts where medical necessity, level of care, or prior authorization is questioned. Additionally, you will perform outpatient post-payment reviews where medical necessity is being challenged. Your responsibilities will also include enterprise-wide outpatient clinical review and appeals on Medicare and Medicaid RAC, PERM, CERT, etc. audits, assisting account representatives with the interpretation of specific payer medical policies, and serving as a liaison with clinical leadership and payer provider representatives. You will create training materials and process flows, participate in projects, and be involved in system testing and development. Furthermore, you will build and analyze management summary reports.

Required Skills and Qualifications:

  • Bachelor's Degree in Nursing
  • Registered Professional Nurse (RN) License Illinois upon hire
  • Three years of experience in healthcare with a focus on reimbursement and/or case management
  • Proficient in Microsoft Office applications such as Word, Excel, Outlook, Access, Visio, Receivables Management systems, and Epic reporting tools
  • Excellent verbal and written communication, negotiation, and listening skills
  • Self-starter with problem-solving skills, able to plan, organize, and achieve goals
  • Ability to multitask, adhere to work plans, and time lines
  • Excellent attention to detail and follow-through

Benefits:

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state, or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization.

Others:

Effective September 20, 2021, the COVID-19 vaccine is required for all new Carle Health team members. Requests for medical or religious exemption will be permitted.



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