Spec. Denials and Appeals - El Paso, TX, United States - University Medical Center of El Paso

Description

Job Description:
The Denials and Appeals Specialist follows up on denied claims from commercial and contracted payers. Performs timely and appropriate validation and follow up for assigned patients.

Communicates with third party nurse reviewers or via clinical documentation inquiry any related missing, unclear or conflicting medical record documentation to clarify information, obtain needed documentation, present opportunities.

Maintains appeal process from the denial stage through final denial or overturned appeal.


Required Skills:
# Knowledge of (ICD) International Classification of Diseases and MS-DRG.
# Knowledge of claims denials and appeals processing.
# Must have working knowledge of DRGs and medical necessity criteria.
# Must possess advanced communication and interpersonal skills with all levels of internal and external customers.
# Must demonstrate excellent written/verbal communication, critical thinking, creative problem-solving, and conflict management skills.
# Must be proficient in organization and planning.
# Must possess strong computer skills including the use of spreadsheets, presentation programs, word processing, and Internet searching.
# Must demonstrate working knowledge of quality improvement theory and practice.
# Knowledgeable of Federal, State, and other payers' regulations, requirements, and criteria.
#


Required Experience:

Work Experience:

Two years of experience with clinical documentation, chart reviewing, utilization review, managed care, and/or claims denials and appeals processing required.

License/Registration/Certification:
Certified Clinical Documentation Specialist preferred.


Education and Training:
Bachelor's degree in related field required.