Job Description

• Effectively review inpatient and/or outpatient medical necessity and authorisation 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.


• Utilise 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 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, lack of authorisation 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