What are the responsibilities and job description for the Clinical Appeal Denial Writer position at Hudson Regional Health?
Position Summary
Manages and reviews clinical denial appeals to payers.
Job Duties
Manages and reviews clinical denial appeals to payers.
Job Duties
- Coordinates appeal for clinical denials to managed care/insurance companies and governmental agencies.
- Writes clinical appeals and audits patient medical and billing records to determine documentation and items billing are appropriate.
- Follows through to ensure that audit adjustments are made and corrective actions are taken to address identified billing, charging, and documentation issues.
- Prepares first, second, and third level appeals utilizing relevant clinical information and professional standards and guidelines.
- Collaborate with each hospital physician advisors and Utilization/Case Managers.
- Performs other duties as assigned
- Possesses and consistently develops the ability to understand medical policies for commercial carriers to determine the medical necessity for audits.
- Remains current with all governmental regulations and policies related to audits including RAC and others. Maintains working knowledge of governmental regulations for billing purposes when performing audits.
- Proposes language changes because of denial reviews and observations.
- Obtains a thorough understanding of managed care contracts as part of appeal process.
- Collaborates with physicians and leadership to enhance denial management and improve clinical documentation improvement efforts.
- Clinical knowledge to denial appeals process.
- Knowledge of regulatory and payer requirements for reimbursement and reasons for denials by auditors.
- Outstanding organization skills.
- Excellent verbal and written communication skills.
- Proficient in Microsoft Office.
- The ability to quickly gain comfort with other software programs needed to perform the essential functions of the position.
- Thorough understanding of clinical processes and knowledge of billing, coding and Milliman Care Guideline (MCG) criteria.
- Three years of experience in acute care utilization review is preferred. Minimum of 1 year Clinical Medical Necessity Appeals preparation.
- Active RN license in the state of NJ. BSN preferred.
Salary : $36 - $42