Denials Prevention Specialist, Clinician PRN
Job Description
The Denials Prevention Specialist plays a critical role in defending utilization of available health services, reviewing admissions for medical necessity, and determining continued stay in the inpatient patient care setting or discharge to an alternative level of care.
• Accurately provide timely referral/appeal determination by utilizing nationally recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise.
• Work under the usage of the Milliman Care Guidelines and/or Interqual.
• Select appropriate letter language to author appeal letters and identify referrals to the medical director for review.
• Select preferred and contracted providers and provide proper identification of eligibility and healthcare plans.
Maintain compliance in turnaround time requirements as mandated by the TAT Standards of the facility and/or CIOX Health Standards. Collaborate with providers and health plan Medical Directors to facilitate timely authorizations and denial reversals.
Meet or exceed production and quality metrics while maintaining confidentiality of all files, documents, and records.
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