Clinical Appeals Specialist

9 hours ago


Enola Pennsylvania, United States PAM Health, LLC Full time
Clinical Appeals Analyst Job Description

PAM Health, LLC is seeking a skilled Clinical Appeals Analyst to join our team. As a Clinical Appeals Analyst, you will play a critical role in assisting the Corporate Director of Appeals Management by conducting comprehensive analytic reviews of clinical documentation and completing the appeal process.

Key Responsibilities:
  • Review patient medical records and utilize clinical and regulatory knowledge to determine why cases/claims are denied and complete an appeal.
  • Develop sound and well-supported appeal arguments using pre-existing criteria sets and clinical evidence from existing libraries of clinical references and regulatory guidelines.
  • Prepare convincing appeal arguments for Administrative Law Judge hearings and participate in hearings by providing testimony, as necessary.
  • Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable.
  • Prepare data and analytics to share with the Director and Executive Team and provide feedback to hospitals regarding trends in denied claims.
  • Discuss documentation-related and level of care decisions with hospitals, independently, as required.
Requirements:
  • Five years' experience as a clinical nurse in an acute care setting.
  • Current state-issued RN license.
  • Significant experience in the healthcare field, including a minimum of five years as a clinical nurse in an acute care setting.
  • Knowledge of regulatory and payer requirements for reimbursement and reason(s) for denials by auditors.
  • Ability to travel as required.
What We Offer:

PAM Health, LLC offers a dynamic and supportive work environment, competitive compensation, and opportunities for professional growth and development.



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