Clinical Appeal Analyst

Successful applicants for this position must be fully vaccinated against COVID-19 as a condition of employment. Vaccine verification will be required.

The Clinical Appeal Specialist is responsible for researching payor medical policies and clinical claims that are eligible for an appeal for their assigned product.  This position develops the clinical rationale to appeal cases, appeal letters, package, and process for the billing vendor to execute while overseeing the clinical appeal process and submission. 

 

PRIMARY RESPONSIBILITIES: 

• Research payor medical policies for coverage requirements for assigned products.  Compare medical literature citations against most relevant published evidence.
• Develop, train, and deploy a process to submit and monitor clinical appeals for assigned products. This includes the required appeal letter and package.
• Review payor denials (letters and portals) for compliance to payor quality standards.  Create custom letters to reply to denials. 
• Expand and exhaust provider level appeals for clinical denials (including but not limited to medical necessity and experimental).
• Develop a patient authorized appeal program for assigned products.
• Monitors claims, identifies trends, presents opportunity areas, and prioritizes initiatives for performance improvement for assigned products.
• Conducts monthly audits on third-party vendors to ensure process and workflows are being adhered and payment accuracy against contracted reimbursement rate.
• Establishes an ongoing working relationship with other departments impacting non-clinical appeal resolution.
• Works closely with the vendor operations teams to oversee operations activity that directly impact the assigned product clinical appeal process.
• Tracks clinical appeal outcomes for assigned products to ensure KPIs and goals are met.
• Participates in weekly meetings to review key metrics, workflows, trends, and performance improvement opportunities.
• Continually reviews and monitors payor appeal changes to determine process update and actions.
• Coordinates with Management to ensure thorough understanding of trends/issues affecting clinical appeal performance.

 

QUALIFICATIONS:

• Bachelor's Degree healthcare related field of study or equivalent experience.
• Minimum of 5 years appeals experience.
• Minimum of 5 years of Utilization Management experience.
• Minimum of 5 years of experience utilizing medical decision support tools or medical policies.
• Knowledge of CPT/HCPCS. ICD-10, modifier selection, and UB revenue codes.
• Active, unrestricted state Registered Nurse (RN) license preferred.
• Minimum of 3 years of experience with Quality Accreditation Standards (JCAHO/ NCQA/ URAC) preferred.
• Project management experience preferred.

 

KNOWLEDGE, SKILLS, AND ABILITIES:

• Proficiency with utilization management process.
• Ability to independently review, research, and analyze medical policies.
• Knowledge of medical or claim billing systems, Microsoft Excel, payor portals, and procedure coding.
• Proficiency with medical terminology and abbreviations, and health care nomenclature and systems.
• Strong communication (verbal and written), organizational, problem solving and team player skills.
• Knowledge of appeal process and procedures.
• Ability to navigate across multiple customer demands and balance competing priorities successfully.
• Ability to analyze, identify and articulate identified trends and report trends succinctly in a clear and concise manner.
• Ability to independently solve complex problems using critical thinking skills.
• Maintains confidentiality of sensitive information.
• Analytical skills required.
• Ability to develop, implement and produce complex analysis and reports.

The pay range for this role is $84,200 - $126,200. Actual compensation packages are based on a wide array of factors unique to each candidate, including but not limited to skill set, years & depth of experience, certifications and specific office location. This may differ in other locations due to cost of labor considerations.  

 

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The pay range is listed and actual compensation packages are based on a wide array of factors unique to each candidate, including but not limited to skill set, years & depth of experience, certifications and specific office location. This may differ in other locations due to cost of labor considerations.Remote - USA$84,200—$126,200 USD

OUR OPPORTUNITY

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