Qual Resource Screener-Denial Management (2972)

A Brief Overview
Responsible for reviewing, analyzing, and appealing claims denied due to a lack of medical necessity. This role ensures compliance with payer requirements, maximizes reimbursement opportunities, and minimizes revenue loss. The position requires collaboration with physicians, case management, coding, utilization review, and payer representatives to secure overturn of denied claims.

What you will do

• Reviews payer denials related to medical necessity and determine the appropriate appeal strategy. • Identify denial trends and escalate systemic issues to leadership for process improvement.
• Prepares, submits, and tracks timely appeals to insurance carriers, ensuring compliance with payer guidelines and regulatory requirements.
• Collaborates with physicians and clinical staff to obtain necessary clinical documentation to support appeals.
• Drafts clear, concise, evidence-based appeal letters citing clinical guidelines, medical policies, and industry standards.
• Uses clinical screening criteria (e.g., MCG, InterQual, and CMS guidelines) to validate medical necessity determinations.
• Documents all appeal activity in the denial management system, ensuring accurate outcomes reporting.
• Participates in quality assurance activities, including retrospective reviews and root-cause analysis of denied claims.
• Maintains up-to-date knowledge of payer medical necessity guidelines, regulatory requirements, and appeal processes.
• Provides education and feedback to case management, coding, and clinical teams on denial prevention opportunities.

Qualifications

• Bachelor's Degree Or equivalent experience in nursing, health information management, healthcare administration, operations management or a related field based on area of assignment. Required and
• Education, training or experience to work with the adolescent, adult and/or geriatric patient population as assignment dictates. Required
• RN, LPN, or equivalent credential strongly preferred. Preferred
• RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required and
• LPN - Licensed Practical Nurse - State Licensure Upon Hire Required and
• RHIA - Registered Health Information Administrator Upon Hire Required
• Minimum 2 years experience In utilization review, case management, health information management, or payer appeals. Required and
• Prior experience with payer appeal processes and medical necessity criteria. Required

Physical Demands

• Standing - Occasionally
• Walking - Occasionally
• Sitting - Constantly
• Lifting - Rarely
• Carrying - Rarely
• Pushing - Rarely
• Pulling - Rarely
• Climbing - Rarely
• Balancing - Rarely
• Stooping - Rarely
• Kneeling - Rarely
• Crouching - Rarely
• Crawling - Rarely
• Reaching - Rarely
• Handling - Occasionally
• Grasping - Occasionally
• Feeling - Rarely
• Talking - Constantly
• Hearing - Constantly
• Repetitive Motions - Frequently
• Eye/Hand/Foot Coordination - Frequently