- File medical necessity and level of care appeals using InterQual and CMS guidelines as needed.
- Monitor clinical appeal processes for issues and trends and provide guidance and feedback to related departments as needed.
- Track and manage clinical denials using current tools (manuals, training programs).
- Identify patterns and trends in denials; communicate to appropriate persons.
- Maintain documentation regarding all payor resources regarding denials and appeals processes.
- Understand and apply CHS 10-Step Appeal Process for denied claims.
- Know medical necessity criteria for outpatient testing and procedures.
- Follow and enforce accepted safety practices for patients and the hospital. Report safety hazards and initiate appropriate action. Participate in safety instructional programs.
- Observe excellent customer service skills when dealing with patients, families and/or significant others, outside vendors, coworkers, and physicians.
- Provide education to staff as appropriate.
- Document all actions accordingly by documentation standards within Artiva, HMS and other business office systems as required.
- Be familiar with policy and procedure manuals and other reference materials.
- Ensure confidentiality of all patient accounts by following HIPAA guidelines
- Perform additional duties as assigned or requested.
- Understanding and utilization of medical necessity criteria for inpatient and outpatient services and procedures.
- Understanding of the revenue cycle and the responsibility and goals of each area
- Must be able to interact with all levels of hospital administration, physicians and other healthcare team members they impact the revenue cycle
- Must be able to follow directions and perform work according to departmental standards and must be able to function effectively under stressful conditions.
- Excellent writing and communications skills as well as effective organizational skills a must.\
- Microsoft office
- Must have diploma/degree from an accredited school of nursing
- 5 years of clinical nursing experience.
- Certificates and Licenses: Current RN license to practice in state
- Utilization review and/or case management experience
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Appeals Specialist
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Clinical Appeals Specialist II - Antioch, United States - Community Health System
Description
Job DescriptionEssential Duties and Responsibilities:
include the following. Other duties may be assigned.
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Knowledge/Abilities:
Required
Reasoning Ability:
Ability to define problems, collect data, validate data, establish facts, and draw valid conclusions
Computer Skills:
Required
Education/Experience:
Required
