Clinical Review Auditor

We know it’s not just about finding a job. It’s about finding a place where you are respected, valued and where your work is purposeful and fulfilling. A place where your talent is recognized, professional development is encouraged and career advancement is possible. Community Health Systems is one of the nation’s leading healthcare providers. Developing and operating healthcare delivery systems in 40 distinct markets across 15 states, CHS is committed to helping people get well and live healthier. CHS operates 70 acute-care hospitals and more than 1,000 other sites of care, including physician practices, urgent care centers, freestanding emergency departments, occupational medicine clinics, imaging centers, cancer centers and ambulatory surgery centers.

(Full-Time, Remote) The Clinical Review Analyst is a professionally licensed nurse/LPN who is responsible for effectively managing the denial/appeal process via the performance of comprehensive analytic reviews of clinical and claim documentation. The CRA will perform triage, determine payment viability; and draft and submit credibly defensible appeals (according to payer guidelines) to obtain appropriate reimbursement for care delivered to patients. As a Clinical Review Analyst at Community Health Systems, you’ll play a vital role in supporting our purpose to help people get well and live healthier by providing safe, quality healthcare, building enduring relationships with our patients, and providing value for the people and communities we serve. Our team members enjoy a robust benefits package including health insurance, flexible scheduling, 401k and student loan repayment programs.

Maintains a working mastery of industry-standard utilization review criteria (i.e.: Interqual), coverage guidelines, and payor medical policies Demonstrates knowledge of governmental, managed care, and commercial denial/appeal policies Appropriately reviews and triages denials for A/R, billing, downgrade, appeal, or denial adjustment Able to prioritize and manage caseload without jeopardizing timely filing Demonstrates excellent technical and clinical skills by drafting credible, defensible appeals Conducts thorough evidence-based clinical literature research to support appeals, as needed Understands and files appropriate levels of appeal (i.e.: reconsideration, dispute, appeal, ALJ…) Accurately enters data into the Appeal Tracker, Cerner/ClaimIQ/Artiva, or other programs Notifies department leadership regarding patterns/trends Together works with department leadership and other Denial Management Team Members to develop and facilitate processes which promote job effectiveness and efficiency Ability to perform all other duties as assigned or requested Ensure confidentiality of all patient accounts by following HIPAA guidelines This is a remote position.