One day hiring process – our calendar is flexible for interviews anytime on Monday onwards.

Job Description

• Effectively review inpatient and/or outpatient medical necessity and authorization denials to determine and understand the validity of such denials promptly


• Should conduct comprehensive reviews of the claim denial and account to make determinations of what action to take to obtain reimbursement.


• Utilize payer policies, MCG, and InterQual criteria to determine if the account meets the criteria for appeal


• Should write an appeal letter to the payer using appropriate clinical indicators, citing Official Coding Guidelines, and documentation from within the patient’s medical record


• Perform all other necessary steps on the specified accounts per Client SOP’s SOPs, including documentation in the EMR, including appeal package creation. Manage the accounts until payment is received, the account is written off, transferred to patient liability, or other adjudication/movement within the system that is appropriate and agreed upon by both Parties


• Reporting quality results, tracking and trending of educational opportunities of the coding and CDI specialists, responding to client subject matter needs, and providing educational support and training

Qualifications:

• PH Registered Nurse with experience in doing medical necessity appeals and lack of authorization appeals. (6 months needed)


• Proficient in reading Explanation of Benefits (EOB) and investigating denial root causes.


• Must be skilled in navigating various payer and provider portals.


• Typing speed of at least 45 WPM.


• Strong command of the English language, both spoken and written.


• Willing to work night shifts to communicate with payers.


• Familiarity with MCG and InterQual is a plus.


• Must NOT hold a USRN license