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About the Role

The Clinician, Denials Prevention, analyzes denials and appeal outcomes, providing clients with opportunities to reduce first pass denials through proper patient status, authorizations, clinical documentation, staff education, and interdepartmental collaboration.

Responsibilities

• Maintain the integrity of information in each appeal produced.
• Review a high volume of written appeals to ensure information is medically accurate.
• Research payer denials related to referral, pre-authorization, notifications, medical necessity, non-covered services, and billing.
• Make recommendations for workflow revisions to improve efficiency and reduce denials.
• Present case studies and recommendations to clients and impacted stakeholders.
• Review payor communications, identifying risk for loss reimbursement related to medical policies and prior authorization requirements.
• Escalate potential issues to clinical stakeholders, managed care contracting, and Revenue Cycle leadership.
• Identify opportunities for process improvement and actively participate in process improvement initiatives.
• Use, protect, and disclose patients’ protected health information (PHI) in accordance with HIPAA standards.
• Comply with Information Security and HIPAA policies and procedures.
• Limit viewing of PHI to the absolute minimum necessary to perform assigned duties.

Requirements

• Bachelor’s degree in a health-related field; 2 years of experience may be considered in lieu of a degree in addition to the required experience.
• LPN or RN preferred.
• Two years of recent experience in hospital case management, hospital prior authorization, or utilization management.
• Experienced in medical chart review.
• Claim-related appeal writing experience preferred.
• Experience with medical and insurance terminology, CPT, ICD coding structures, and billing forms.
• Experience with MCG and/or InterQual guidelines preferred.
• Proficiency in Microsoft Office Suite.
• Strong interpersonal skills, ability to communicate well at all levels of the organization.
• Strong problem-solving and creative skills.
• Ability to exercise sound judgment and make decisions based on accurate and timely analyses.
• High level of integrity and dependability with a strong sense of urgency and results orientation.
• Excellent written and verbal communication skills.
• Gracious and welcoming personality for customer service interaction.
• Must possess a smart-phone or electronic device capable of downloading applications for multifactor authentication and security purposes.

Skills

• Medical chart review
• Claim-related appeal writing
• Medical and insurance terminology
• CPT coding
• ICD coding
• Billing forms
• MCG guidelines
• InterQual guidelines
• Microsoft Office Suite
• Interpersonal skills
• Communication skills
• Problem-solving skills
• Creative skills
• Judgment
• Decision-making
• Integrity
• Dependability
• Urgency
• Results-oriented
• Written communication
• Verbal communication
• Customer service

Experience Level

• Two years of recent experience in hospital case management, hospital prior authorization, or utilization management

Education Level

• Bachelor’s degree in a health-related field
• LPN
• RN

About the Company

• Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.

Equal Opportunity

• Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.