- – Appeals and Denials Coordinator POSITION DUTIES – The Coordinator-Clinical Appeals is responsible for the support of the daily function and operations of the Billing and Collections department by reviewing and appealing clinical denials as well as retro authorizations. Interfaces with payors, Case Managers, Insurance Verification department, Financial Counselors, PBO, and Health Information Management department. Reviews medical records for medical necessity of admission, severity of illness, and intensity of service based on InterQual and Milliman Guidelines. Documents in appropriate systems the results of retro authorization and denial or appeal efforts. Reviews referred accounts for appropriate trauma charges, as well as NICU when requested, when charges are inconsistent. Composes and sends appeal letters to payor when denial is in violation of state and federal laws as well as due to lack of sufficient information sent to payor. Evaluates and reviews in-patient hospitalizations for delay of service and delay of discharge. Reviews all findings and appeal letters with Denial Clinical Appeals Unit (CAU) Management. Participates in department quality improvement projects. Performs other duties as needed. MINIMUM REQUIRED QUALIFICATIONS –
- Recent experience in specialty
- BLS
- California Vocational Nurse (LVN) license or Medical Terminology certification
– Nationally recognized certification in Utilization Management, Utilization Review, Hospital Utilization, Managed Care or Health Care related area LENGTH OF ASSIGNMENT – 22 weeks SHIFT / HOURS PER WEEK – 8a-5p SYSTEMS – Epic START DATE – ASAP