Clinical Appeal - Denial Writer

September 20

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Ovation Healthcare

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revenue cycle • clinical services • supply chain • hospital management • hospital operations

201 - 500

Description

• Clinical appeal writer conducts the medical review activities needed to resolve and process clinical appeals and claims. • Reviews applicable medical records and assesses clinical data to investigate and resolve disputes over the medical necessity for services, approvals, pre-certifications, or other cases. • Understands and interprets applicable medical terminology, clinical procedures, regulations, and policies. • Documents cases according to guidelines and standard procedures. • Prepares the documentation required for further medical review, hearings, and different appeal processes. • Responsible for submission of clinical appeals for all payors, service types, and denial reasons. • Understands reimbursement methodology impacting payment variance including: DRG downgrade, line item denials, service level, and fully denied accounts. • Work effectively with denial management team and denials analyst to appeal all denials referred. • Supporting projects and initiatives of the Denials Management Team, to include coordinating meetings, conducting research, performing audits or data analysis, and preparing documents. • Maintains strictest confidentiality; adheres to all HIPAA guidelines/regulations. • Provides precise documentation of all actions taken on accounts worked. • Maintains client and/or position specific daily productivity and quality expectations.

Requirements

• Healthcare background is required, preferred to have knowledge in revenue cycle. • The ability to work in a fast-paced environment balancing multiple priorities and utilizing resources. • Requires the ability to interpret all aspects of a contract with an emphasis on the implementation and operational components of contract terms. • Must be a self-starter with the ability to identify, understand and research issues specific to payor contracts. • MS Office Tools. • Excellent interpersonal skills are necessary to develop strong working relationships with internal and external contact. • Experience with various electronic medical records and understand HIPAA and PHI privacy and security. • A team player, always willing to contribute to the whole of the organization. • Must be able to pass as skills assessment exam, comprehensive and background check.