Summary
The Clinical Appeals Coordinator is responsible for supporting Concord Hospital with claim appeal activities within the Revenue Integrity department. This involves a timely and accurate review of medical records in response to claim denials received from third party payers, Recovery Audit Contractors (RAC), Medicare Administrative Contractors (MAC), as well as medical necessity denials from other governmental and non-governmental payers and auditors. The Clinical Appeals Coordinator will evaluate opportunities for education and provide feedback to physicians the RCC Committee, and other relevant departments. Additionally, this person will serve as a clinical resource to the entire Revenue Management division.
Education
Bachelor's degree in Nursing from an accredited Nursing program.
Certification, Registration & Licensure
Experience
Minimum of five years’ experience in utilization review and/or auditing in an acute-care hospital setting. Medicare audit and appeal background strongly desired. Must have solid understanding of Medicare levels of care (inpatient/observation). Experience applying Milliman and/or Interqual guidelines required. Familiarity with medical coding, reimbursement, and insurance practices required. Must possess excellent interpersonal, communication, and motivational skills, including the ability to communicate clearly and concisely, both orally and in writing. Ability to work collaboratively with individuals at all levels throughout the organization required. Strong facilitation and presentation skills required. Must use independent judgment in reviewing records to determine appropriate appeal action. Must be able to compose a persuasive appeal using clinical data, regulatory guidelines, evidence-based standards, and applicable legal statute. Strong organizational and time management skills required. Must be able to independently prioritize work. Strong critical-thinking and problem solving skills required. Must be flexible and comfortable in an environment with frequent changing demands and requirements. Strong computer skills required including MS Word and Excel.
Responsibilities
Performs audits on all assigned clinical denials.
Constructs all necessary appeals with payers for reconsideration of denied charges and/or services.
Identifies root cause of denials and provides education to Care Managers, Providers and Charge Departments as appropriate.
Acts as a clinical resource to Patient Financial Services and other Concord Hospital departments for payment/charge issues and other clinical inquiries that may or may not be related to audits and appeals.
Takes responsibility for individual performance goals.
Performs other duties as assigned.
Concord Hospital is an Equal Employment Opportunity employer. It is our policy to provide equal opportunity to all employees and applicants and to prohibit any discrimination because of race, color, religion, sex, sexual orientation, gender, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.
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