Clinical Denials & Appeals Specialist (RN) - Remote

Reviews and responds to Corporate Compliance Audits and serves as a resource for the Health System. Reviews denial trends and identifies coding issues and knowledge gaps.

Serves as liaison between the patient and facility/physician and the third party payer. Prepares and defends level of care and medical necessity for assigned case. Collaborates with physician advisor, payor representative and site case managers to facilitate appropriate level of care decisions and billing status and ensures compliance with the Utilization Review standard and regulations. Performs concurrent and retrospective utilization management using evidenced-based medical necessity criteria; conducts clinical reviews and formulates appeal letters to support appropriateness of admission and continued length of stay. Ensures compliance with current state, federal, and third-party payer regulations. Ensures clinical reviews and appeals are up to date and accurately reflect patient’s severity of illness and intensity of services provided. Performs PRI’s (Patient Review Instrument), as needed. Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.