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About the Role

Manage medical denials by conducting comprehensive analytic reviews of clinical documentation to determine if an appeal is warranted. Utilize clinical background to address clinical denials and write compelling arguments for appeals. Maintain knowledge of Third Party Payors and Governmental Payors clinical/medical necessity criteria and file compliant appeals.

Responsibilities

• Review assigned cases comparing the bill to the medical record.
• Compare charges to documentation to ensure services documented are captured and services not documented are not charged.
• Review documentation to ensure services typically performed with specific procedures are documented for charge capture.
• Review findings with hospital representatives and obtain agreement on discrepancies.
• Follow up on appeals in a timely fashion.
• Re-check mathematical computations before finalizing letters and reports.
• Update status of all assigned cases on a minimum weekly basis.
• Inform supervisor of any changes, problems, or concerns.
• File appeals with third party or governmental payors in the event of a dispute.
• Analyze and interpret all medical necessity/clinical denials from third party or governmental payors.
• File appeals based on medical documentation and interpretation of medical necessity guidelines or InterQual criteria.

Requirements

• 5 years of clinical healthcare/hospital experience
• 3 years of related Anesthesia experience
• Third Party Payor Appeals/Revenue Cycle experience
• Current RN license in State of employment
• Working experience with Utilization Review activities
• General knowledge of TJC, PRO, and other regulatory bodies
• High School Diploma/GED

Skills

• Anesthesia
• Medical denials management
• Clinical documentation review
• Appeal writing
• Third Party Payor knowledge
• Governmental Payor knowledge
• Medical necessity criteria
• Utilization Review
• TJC
• PRO

Experience Level

• 5 years clinical healthcare/hospital experience
• 3 years related Anesthesia experience

Education Level

• High School Diploma/GED
• Bachelor's degree - BSN highly desired

Salary/Compensations

• $80,912.00 - $121,388.80

About the Company

• Shriners Children’s is an organization that respects, supports, and values each other.
• Named as the 2025 best mid-sized employer by Forbes.
• Engaged in providing excellence in patient care, embracing multi-disciplinary education, and research with global impact.
• Foster a learning environment that values evidenced based practice, experience, innovation, and critical thinking.
• Compassion, integrity, accountability, and resilience define us as leaders in pediatric specialty care for our children and their families.
• With 20+ hospitals, outpatient clinics, ambulatory care centers and outreach locations across the globe, we provide excellent care to children up to age 18 regardless of their family’s ability to pay or insurance status.