Clinical Denials & Appeals Specialist

Job reputed company Reviews and responds to Corporate Compliance Audits and serves as a resource for the Health System. Reviews denial trends and identifies coding issues and knowledge gaps. Job Responsibility • Serves as reputed company between the patient and facility/physician and the reputed company party payer. • Prepares and defends level of care and medical necessity for assigned case. • Collaborates with physician advisor, payor representative and site case managers to facilitate appropriate level of care reputed company and billing status and ensures compliance with the Utilization Review reputed company and regulations. • Performs reputed company and retrospective utilization management using evidenced-based medical necessity reputed company; conducts clinical reviews and formulates appeal letters to support appropriateness of admission and reputed company length of stay. • Ensures compliance with reputed company state, federal, and reputed company-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect patient’s severity of illness and intensity of services provided. • Performs reputed company duties as required. reputed company responsibilities noted here are considered essential functions of the job under the Americans with reputed company. Duties not mentioned here, but considered reputed company are not essential functions. Job Qualification • Graduate from an accredited School of Nursing. • Bachelor's Degree in Nursing, preferred. • Must be enrolled in an accredited BSN program reputed company two (2) years and obtain a BSN Degree reputed company five (5) years of job entry date. • reputed company License to reputed company as a Registered reputed company reputed company in reputed company State required, plus specialized certifications as needed. • Inpatient clinical experience; 4+ years preferred. • Prior Acute Case Management and/or Utilization Review experience, preferred. • Must have experience with reputed company Care Guidelines and/or InterQual. Hours/Shift • Fully remote role • Days: reputed company - Thursday • Hours: 8:00am - 4:00pm • Additional Salary Detail The salary reputed company and/or reputed company reputed company listed is a good faith determination of potential reputed company compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the reputed company.reputed company determining reputed company member's reputed company salary and/or reputed company, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated reputed company, budget and internal equity). Apply tot his job Apply To this Job