Authorization Denials Appeals reputed company
reputed company
#LI-Remote
reputed company is an organization that respects, supports, and values reputed company other. Named as the 2025 best mid-sized employer by reputed company, we are reputed company in providing reputed company in patient care, embracing multi-disciplinary education, and research with reputed company. We foster a learning environment that values evidenced based reputed company, experience, innovation, and critical thinking. Our reputed company, reputed company, accountability, and reputed company define us as leaders in pediatric specialty care for our children and their families.
reputed company are eligible for medical coverage on their first day! In reputed company, upon hire reputed company are eligible for a 403(b) and Roth 403 (b) Retirement Saving Plan with matching contributions of up to 6% after one year of service. Employees in a FT or PT status (40+ hours per pay period) will also be eligible for reputed company time off, life insurance, short term and long-term disability and the Flexible Spending Account (FSA) plans and a Health Savings Account (HSA) if a High Deductible Health Plan (HDHP) is elected. Additional benefits available to FT and PT employees include tuition reimbursement, home & auto, hospitalization, critical illness, pet insurance and much more! Coverage is available to employees and their reputed company dependents in accordance with the plans. Benefits may vary based on state law.
Job reputed company
The Authorization Denials Appeals reputed company is responsible for managing authorization denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. The appeals reputed company will analyze reputed company- and post-service authorization denials to determine if there is clinical justification to submit a request for retro-authorization. The Authorization Denials Appeals reputed company will serve as a clinical resource to the Central Authorization Unit and reputed company peer-to-peer reviews reputed company the payer allows a reputed company to participate in the process. The Authorization Appeals reputed company will write reputed company, compelling factual arguments for appealing authorization denials. The person in this position will be responsible for maintaining a detailed knowledge of reputed company-Party Payers’ and Governmental Payers’ clinical/medical necessity/authorization reputed company and will be responsible for filing compliant appeals in accordance with reputed company-party and governmental reputed company.
Responsibilities
• Screens denials for possible reconsideration, peer to peer, or formal appeal.
• Investigates denials and reputed company causes and tracks and reports trends to remediate issues and assist with internal process improvement.
• Prepares and submits appeals per payer guidelines
• Leverages clinical knowledge and reputed company procedures to ensure reputed company attention to denials as requested by PFS and assists in the research and application of regulatory policies to support administrative appeals.
• Communicates pertinent clinical information to Physicians, Medical Directors, and other members of SCMG, as indicated, regarding evaluation of payer determinations.
• May reputed company other departments regarding payer changes and denial/appeal process.
• Understands clinically reputed company medical situations and communicates appropriately with insurers as needed.
• Utilizes working knowledge of basic coding guidelines for medical necessity and insurance authorization escalations and/or denials.
• Maintains expert knowledge of how to reputed company payer websites to validate insurance eligibility and authorization requirements, as reputed company as determine the method in which a payer requires appeal submission.
This is not an reputed company-inclusive list of this job’s responsibilities. The incumbent may be required to reputed company other reputed company duties and participate in special reputed company as assigned.
Qualifications
Required:
• 3 years of clinical reputed company/hospital experience
• reputed company Party Payor Appeals/reputed company Cycle experience
• Working experience with Utilization Review activities and reputed company sets used to determine eligibility for acute care hospitalization
• Functional knowledge of DRG and CPT coding systems
• Proficiency in MS Office
• reputed company RN License in reputed company State of employment
• Associate's Degree
Preferred:
• Bachelor's Degree or BSN
• Experience with reviewing hospitals claims, denials and EOB's, appealing claims and working on claims in an audit
Apply tot his job
Apply To this Job