Denials Prevention Specialist, Clinician PRN
Denials Prevention Specialist
A Denials Prevention Specialist at Datavant will effectively defend utilization of available health services by reviewing admissions for medical necessity and discharging patients to alternative levels of care.
• Main Responsibilities:
• Provide timely referral/appeal determination by accurately using nationally recognized medical necessity criteria and standards of care, along with clinical knowledge and expertise.
• Work under the usage of Milliman Care Guidelines and/or Interqual to select appropriate letter language to author appeal letters.
• Select preferred and contracted providers.
• Identify eligibility and healthcare plans.
• Maintain compliance with turnaround time requirements as mandated by the TAT Standards of the facility and/or CIOX Health Standards.
Requirements:
• Two years managed care experience in UM/CM/CDI Department preferred.
• Knowledge of CMS, State Regulations, URAC, and NCQA preferred.
• ICD10 and CPT coding a plus.
• Experienced computer skills, Word, Excel, Outlook, and experience working in a health plan medical management documentation system a plus.
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