Clinical Appeals Specialist | PAM Health Corporate

Overview

Clinical Appeals Analyst (Remote) - FT

The Clinical Appeals Specialist is responsible for assisting the Corporate Director of Appeals Management (hereafter known as “Director”) by conducting a comprehensive analytic review of clinical documentation and complete the appeal process. The Clinical Appeals Specialist will write sound, compelling letters to support the appeal. They may also attend Administrative Law Judge hearings, handle audit related correspondence and other administrative duties as required. This is an exempt position.

Responsibilities

I. Job Responsibilities:

 

· Review patient medical records and utilize clinical and regulatory knowledge and skills, as well as, knowledge of payer requirements to determine why cases/claims are denied and complete an appeal.

· Utilize pre-existing criteria and other resources and clinical evidence to develop sound and well-supported appeal arguments.

· Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory guidelines to prepare the response to the payer in an effort to overturn the denial in a professional and concise manner.

· Prepare convincing appeal arguments, using pre-existing criteria sets and/or clinical evidence from existing library of clinical references and/or regulatory guidelines to prepare for an Administrative Law Judge hearing and participate in hearings by providing testimony, as necessary.

· Search for supporting clinical evidence to support appeal arguments when existing resources are unavailable. Actively seek out opportunities for appeal by reviewing all insurance denials within assigned region.

· Prepare data and analytics and share with the Director and Executive Team and provide feedback to hospitals regarding trends in denied claims.

· Discuss documentation-related and level of care decisions with hospitals, independently, as required.

· Have the ability to proficiently read, understand and communicate in writing abstract information from patient medical records in a professional manner. Demonstrates excellent written communication. Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; presents numerical data effectively; able to read and interpret written information

· Ensure compliance with HIPAA regulations, including confidentiality, as required.

· Demonstrates excellent written communication. Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; presents numerical data effectively; able to read and interpret written information.

· Other duties as assigned.

· Audit selected medical records to determine compliance with CMS guidelines and regulations. Coordinate with hospitals to correct any deficiencies prior to submission of records to auditors. Coordinate with government auditors to provide additional information as needed and set up educational sessions with hospitals following completion of audits. Maintain all required documentation related to assigned audits.

 

II. Leadership

 

· Inclusiveness: Promotes cooperation, fairness and equity; shows respect for people and their differences; works to understand perspectives of others; demonstrates empathy; brings out the best in others and in his/her team.

· Stewardship and Resource Management: Demonstrates accountability and sound judgment in managing company resources. Appropriate understanding of confidentiality and company values. Adheres to and supports company policies, procedures and safety guidelines.

· Problem-Solving: Identifies problems, involves others in seeking solutions. Conducts appropriate analysis. Searches for best solutions. Effectively and efficiently implements appropriate response to correct problems. Responds promptly and effectively to new challenges.

· Decision-Making: Makes clear, consistent decisions. Acts with integrity in all decisions. Distinguishes relevant from irrelevant information. Makes timely, appropriate decisions.

· Communication: Connects with peers, subordinate employees and all customers. Actively listens. Clearly and effectively shares information. Demonstrates effective oral and written communication skills. Negotiates effectively.

· Quality Improvement: Strives for efficient, effective, high-quality performance in self and the department. Delivers timely and accurate results. Resilient when responding to matters that are challenging. Takes initiative to make improvements.

· Teamwork: Encourages cooperation and collaboration. Builds effective teams. Works in partnership with others. Is flexible. Responsive to the needs of others.

· Development: Maintains up-to-date skills through involvement with professional