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Clinical Appeals Coordinator
2 months ago
XSOLIS, Inc. is seeking a highly skilled Clinical Appeals Coordinator to join our team. As a Clinical Appeals Coordinator, you will play a critical role in providing concurrent review and appeal support services for our growing client base.
Key Responsibilities- Provide clinical reviews in accordance with Managed Care and CMS Regulatory Requirements to assist with assigning appropriate level of care on a case-by-case basis.
- Determine if ICD-10 codes/DRG appropriately documented and meet clinical documentation integrity guidelines.
- Assist with the denial management process and construction of appeal correspondence.
- Determine if professionally recognized standards of quality care are met.
- Provide feedback to internal and external partners regarding level of care, length of stay, rationale on outcomes of cases, and clinical documentation for ICD-10s.
- Apply clinical and industry guidelines, and use of in-depth knowledge that supports medically necessity of services rendered, and clinical documentation integrity of ICD-10s.
- Identify opportunity to request additional, more complete, medical record documentation Review cases with screening criteria, such as InterQual, MCG or other appropriate platforms.
- Review cases with screening criteria (CDI), Pinson & Tang, ACDIS, along with familiarity with payer CDI guidelines.
- Continually keep abreast of technology changes, regulatory issues, and medical practice through ongoing training and self-directed research.
- Provide client with a detailed Summary of Cases to track any discovery of trends or other pertinent information.
- Research/Review contracts and speak to the payer on behalf of the client on why a claim decision was made.
- Ensures legal compliance by following guidelines, contracts, regulations, and the company's business plan.
- Active RN or LPN license.
- 3-5 years of clinical practice, with at least 2 of these years in auditing, appeals, medical review, and CDI.
- Case management or Utilization Review experience and CM, coding and/or CDI certification a plus.
- Experience working with multiple instances of Electronic Medical Records (i.e. Meditech, Cerner, EPIC).
- Knowledge of the query process and utilization of CDI guidelines (Pinson & Tang, ACDIS, etc.).
- Experience using case management guidelines (InterQual, Milliman, CMS 2MN Rule).
- Excellent communication skills.
- CPT, ICD-10, and DRG coding.
- MS Office Suite - Specifically Word and Excel.
- Organization and prioritization.
- Medical record technology.
- Adobe DC/PDF.
XSOLIS, Inc. is a dynamic and entrepreneurial healthcare technology organization focused on creating an environment for our clients where care givers spend more time with patients and less time with their heads down in paperwork. For the first time, healthcare operations can leverage clinical and risk scoring methodologies to better manage medical necessity determinations, patient flow, patient hand-offs, payer/provider communication, accurate reimbursement.
